CMS-276 Inventory-Cost Report

Cost Report PRA Package Inventory
Document
4th Quarter Report - Excel
PDF of Budget
Cost Report Instructions – Word
Cost Report Instructions – PDF
Crosswalk for Budget Report Revisions
Crosswalk for 4th Quarter and Final Report Revisions
Final Report - Excel
Form 83 – PRA Submission WS – Part I: Info Collection Request
Form 83 – PRA Submission WS – Part II: Info Collection Detail
(HCPPs)
Form 83 – PRA Submission WS – Part II: Info Collection Detail
(HMO/CMPs)
Interim Report - PDF
Interim Report - Excel
Notice of OMB Action (Dated 10/26/2009)
Record of Info Collection Clearances

Complete
Date

Notes

No action on DCPA
may be necessary?
Minor document – If
revising the package,
this must be signed
by the Center
Director, and a
crosswalk of changes
must be submitted. If
only minor changes
are made, the group
director can sign.

Revised Cost Report – Clean Version - word
Supporting Statement for CMS-276: Prepaid Health Plan Cost
Report - Word

Little updating will
be necessary

OMB Form 83 Parts I and II:
Part I: Info Collection Request
Part II: Information Collection Details

4 pages (see above)
4 pages (see above)

Supporting Statements – specific details of request:
Supporting Statement A

Supporting Statement B

Collection Instruments and Instructions:
Must submit copy of cost report and instructions.
Disclosure Statement

See above – we have
already created this,
it only needs
updating.
Do not need to
complete?

Need to complete.

Crosswalk Document

Can work off Frank’s

Record of Information Clearances

See notes above.

Must create a document answering the ‘Additional Information’
request – Info re: PII