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Medicare Parts C and D Program Audit Protocols and Data Requests
 
No Modified
 
Mandatory
 
42 CFR 423.505 42 CFR 423.514 42 CFR 422.504

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10191 CPE Program Area Audit Process and Data Request Attachment_I_CPE_AuditProcess_DataRequest.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10191 CPE Self-Assessment Questionnaire Attachment_I-A_CPE_Self-Assessment_Questionnaire_SA-Q.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10191 CPE Compliance Officer Questionnaire Attachment_I-B_CPE_Compliance _Officer_Questionnaire_CO-Q.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10191 CPE Audit Organizational Structure and Governance PPT Template Attachment_I-C_CPE_Organizational_Structure_Governance _PPT_ Template.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10191 Accountability for Oversight of First-Tier, Downstream and Related Entities Questionnaire Attachment_I-D_CPE_FDR_Oversight_Questionnaire_FDR-Q.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10191 SIU/FWA Prevention and Detection Questionnaire Attachment_I-E_CPE_SIU_FWA_Questionnaire_FWA-Q.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10191 FA AUDIT PROCESS AND DATA REQUEST Attachment_II_FA_AuditProcess_DataRequest.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10191 CDAG AUDIT PROCESS AND DATA REQUEST Attachment_III_CDAG_AuditProcess_DataRequest (2).pdf Yes Yes Fillable Fileable
Form CMS-10191 CDAG Supplemental Questions Attachment_III-A_CDAG_SupplementalQuestions.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10191 ODAG AUDIT PROCESS AND DATA REQUEST Attachment_IV_ODAG_AuditProcess_DataRequest.pdf Yes Yes Fillable Fileable
Form CMS-10191 ODAG Supplemental Questions Attachment_IV-A_ODAG_SupplementalQuestionnaire.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10191 SNP-MOC AUDIT PROCESS AND DATA REQUEST Attachment_V_SNP-MOC_AuditProcess_DataRequest.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10191 MTM PILOT AUDIT PROCESS AND DATA REQUEST Attachment_VI_MTM_AuditProcess_DataRequest.pdf Yes Yes Fillable Fileable
Form CMS-10191 CDAG CDM Impact Analysis CDAG_CDM_Impact.pdf Yes Yes Fillable Fileable
Form CMS-10191 CDAG GRV Impact Analysis CDAG_GRV_Impact.pdf Yes Yes Fillable Fileable
Form CMS-10191 FA Impact Analysis FA_ImpactAnalysis_.pdf Yes Yes Fillable Fileable
Form CMS10191 MTM Impact Analysis MTM_ImpactAnalysis.pdf Yes Yes Fillable Fileable
Form CMS-10191 ODAG CDM Impact Analysis ODAG_CDM_Impact.pdf Yes Yes Fillable Fileable
Form CMS-10191 ODAG DIS Impact Analysis ODAG_DIS_Impact.pdf Yes Yes Fillable Fileable
Form CMS-10191 ODAG GRV Impact Analysis ODAG_GRV_Impact.pdf Yes Yes Fillable Fileable
Form CMS-10191 ODAG PMNT Impact Analysis ODAG_PMNT_Impact.pdf Yes Yes Fillable Fileable
Form CMS-10191 SNP-MOC ICP ICT Impact Analysis SNP-MOC_ICP_ICT_Impact.pdf Yes Yes Fillable Fileable
Form CMS-10191 SNP-MOC Impact Analysis SNP-MOC_Impact.pdf Yes Yes Fillable Fileable
Form CMS-10191 SNP-MOC Training Impact Analysis SNP-MOC_Training_Impact.pdf Yes Yes Fillable Fileable
Form CMS-10191 Pre-Audit Issues Summary Pre-AuditIssueSummary.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

201 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   90 %

  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 241 0 46 0 0 195
Annual IC Time Burden (Hours) 52,261 0 28,666 0 0 23,595
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Crosswalk Crosswalk_of_Revisions.pdf 12/09/2016
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.