Qualification-Medicare Advantage Application for Coordinated Care Private Fee-For-Service, Regional Preferred Preferred Provider Organization, Service Area Expansion for Coordinated Care.......
ICR 200501-0938-002
OMB: 0938-0935
Federal Form Document
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0938-0935 can be found here:
Qualification-Medicare
Advantage Application for Coordinated Care Private Fee-For-Service,
Regional Preferred Preferred Provider Organization, Service Area
Expansion for Coordinated Care.......
New
collection (Request for a new OMB Control Number)
This information
collection is approved with the following condition of clearance.
HHS/CMS will solicit comments on the application during the
scheduled training sessions and will report back to OMB within one
week of the conclusion of these sessions with a plan to address
these comments through modifying the application, issuing
clarifying instructions, or other means.
Inventory as of this Action
Requested
Previously Approved
06/30/2005
06/30/2005
350
0
0
20,100
0
0
0
0
0
Prepaid health plans must meet certain
regulatory requirements to enter into a contract with CMS to
provide health benefits to Medicare beneficiaries. These
applications are the collection forms to obtain the information
from a health plan that will allow CMS staff to determine
compliance with the regulations.
On behalf of this Federal agency, I certify that
the collection of information encompassed by this request complies
with 5 CFR 1320.9 and the related provisions of 5 CFR
1320.8(b)(3).
The following is a summary of the topics, regarding
the proposed collection of information, that the certification
covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a
benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control
number;
If you are unable to certify compliance with any of
these provisions, identify the item by leaving the box unchecked
and explain the reason in the Supporting Statement.