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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
QHP Certification
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
45 CFR 155.1065
45 CFR 156.200
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CMS-10433
Data Template Administrative
A1 Administrative.xlsm
Yes
Yes
Fillable Fileable
Form
CMS-10433
Medical Essential Community Providers
A2.1 Medical ECP.xlsm
Yes
Yes
Fillable Fileable
Form
CMS-10433
Dental Essential Community Provider
A2.2 Dental ECP.xlsm
Yes
Yes
Fillable Fileable
Form
CMS-10433
URAC Application
A3.1 URAC.xlsm
Yes
Yes
Fillable Fileable
Form
CMS-10433
NCQA Template
A3.2 NCQA.xlsm
Yes
Yes
Fillable Fileable
Form
CMS-10433
AAAHC
A3.3 AAAHC.xlsm
Yes
Yes
Fillable Fileable
Form
CMS-10433
Network Adequacy
A4 NetworkAdequacy.xlsm
Yes
Yes
Fillable Fileable
Form
CMS-10433
Program Attestations
A5 Program Attestations.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10433
Accreditation Attestations
A6 Accreditation Attestation.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10433
Plan and Benefit
B1 Plan and Benefits.xlsm
Yes
Yes
Fillable Fileable
Form
CMS-10433
Prescription Drugs Template
B2 Prescription_Drugs_Template.xlsm
Yes
Yes
Fillable Fileable
Form
CMS-10433
Service Area
B3 ServiceArea.xlsm
Yes
Yes
Fillable Fileable
Form
CMS-10433
Network ID
B4 NetworkID.xlsm
Yes
Yes
Fillable Fileable
Form
CMS-10433
Rates Table
C1 RatesTable.xlsm
Yes
Yes
Fillable Fileable
Form
CMS-10433
Business Rules
C2 Business Rules.xlsm
Yes
Yes
Fillable Fileable
Instruction
CMS-10433_Appendix D RI RA Banking and Edge Server ( 7-23-14) clean(2).pdf
Yes
Yes
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:
975
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:
100 %
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
975
0
0
0
0
975
Annual IC Time Burden (Hours)
182,325
0
0
0
0
182,325
Annual IC Cost Burden (Dollars)
0
0
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.