View Information Collection (IC)
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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
DE Entity Operational Readiness Review (ORR)
Agency IC Tracking Number:
CCIIO - 10877
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
45 CFR 155.221
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
CMS-10877
Documentation and Audit Package
Appendix_E_DEE-Documentation-Package_v1.7_508.pdf
Yes
No
Paper Only
Form and Instruction
CMS-10877
Privacy Questiionaire
Appendix_F_EDE-Privacy-Questionnaire_08.02.22_508.pdf
Yes
Yes
Fillable Fileable
Instruction
Appendix_G_API-Functional-Integration-Toolkit_03.31.23_508.pdf
Yes
No
Paper Only
Form and Instruction
CMS-10877
Application User Interface Toolkit
Appendix_H_Application-UI-Toolkit_v3.1_03.31.23_508.pdf
Yes
No
Fillable Printable
Form and Instruction
CMS-10877
Communications Toolkit
Appendix_J_EDE-Business-Audit-Instructions-Report-Template_PY2024_508.pdf
Yes
Yes
Paper Only
Form and Instruction
CMS-10877
Eligibility Results Toolkit
Appendix_K_EDE-Eligibility-Results-Toolkit-Phase1_PY2023_Final_508.pdf
Yes
No
Fillable Fileable
Form and Instruction
CMS-10877
Eligibility Results Toolkit - Phase 2
Appendix_L_EDE-Eligibility-Results-Toolkit-Phase2_PY2023_Final_508.pdf
Yes
No
Fillable Fileable
Form and Instruction
CMS-10877
Eligibility Results Toolkit - Phase 3
Appendix_M_EDE-Eligibility-Results-Toolkit-Phase3_PY2023_Final_508.pdf
Yes
No
Fillable Fileable
Form and Instruction
CMS-10877
Change Notification Form
Appendix_N_EDE-Entity-Initiated-Change-Notification-Form_v2_508.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10877
Business Agreement BY 2024
Appendix_O_EDE_Business_Agreement_PY_2024_Final_508.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10877
INTERCONNECTION SECURITY AGREEMENT
Appendix_Q_CMS-EDE-ISA-Template_v3.4_Final_508.pdf
Yes
No
Fillable Fileable
Form and Instruction
CMS-10877
EDE Communication Toolkit
Appendix_I_EDE-Communications-Toolkit_03.10.23_508.pdf
Yes
No
Fillable Fileable
Form and Instruction
CMS-10877
SAP Template
Appendix_P_NEE-EDE-SAP-Template_v3.1_Final_02.24.22_508.pdf
Yes
No
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
95
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Not-for-profit institutions, Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
95
95
0
0
0
0
Annual IC Time Burden (Hours)
2,689
2,689
0
0
0
0
Annual IC Cost Burden (Dollars)
200,372
200,372
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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