Information Collection

Chronic Care Improvement Program and Medicare Advantage Quality Improvement Project

IC 179877 under ICR 201111-0938-008 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Chronic Care Improvement Program and Medicare Advantage Quality Improvement Project	Form and Instruction
CMS-10209.CCIP User Guide (05-31-2012).docx	Instruction
CMS-10209.QIP User Guide for OMB 05-31-12.docx	Instruction
CMS-10209 CCIP_Reporting_Tool CMS-10209_CCIP_Reporting_Tool _Final.pdf	Form and Instruction
CMS-10209 QIP_Reporting_Tool CMS-10209_QIP_Reporting_Tool_Final.pdf	Form and Instruction

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 422.152(a)(1) and (2)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10209	CCIP_Reporting_Tool	CMS-10209_CCIP_Reporting_Tool _Final.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10209	QIP_Reporting_Tool	CMS-10209_QIP_Reporting_Tool_Final.pdf	Yes	Yes	Fillable Fileable
Instruction			CMS-10209.CCIP User Guide (05-31-2012).docx	No		Printable Only
Instruction			CMS-10209.QIP User Guide for OMB 05-31-12.docx	No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 952

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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,904	1,116	788
Annual IC Time Burden (Hours)	28,560	9,648	18,912
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.