Information Collection

Chronic Care Improvement Program and Medicare Advantage Quality Improvement Project

IC 179877 under ICR 201007-0938-016 · OMB 0938-1023.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1023 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS 10209-CCIP Chronic Care Improvement Program and Medicare Advantage Quality Improvement Project	Form and Instruction
CMS 10209-CCIP Chronic Care Improvement Program Reporting Template #3.CCIP ReportingTemplate .docx	Form and Instruction
CMS 102-QIP Medicare Advantage Quality Improvement Project Reporting #3.QIP Reporting Template.docx	Form and Instruction
#3. TA Survey.docx #3	IC Document

IC Title:

Chronic Care Improvement Program and Medicare Advantage Quality Improvement Project

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.152a 42 CFR 422.152(a)(1) and (2)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS 10209-CCIP	Chronic Care Improvement Program Reporting Template	#3.CCIP ReportingTemplate .docx		Yes	Yes	Paper Only
Form and Instruction	CMS 102-QIP	Medicare Advantage Quality Improvement Project Reporting Template	#3.QIP Reporting Template.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 394

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	788	-64	852
Annual IC Time Burden (Hours)	18,912	9,685	9,227
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
#3	#3. TA Survey.docx	07/09/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.