Information Collection

Medicare Parts C and D Universal Audit Guide

IC 43683 under ICR 201307-0938-024 · OMB 0938-1000.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1000 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Medicare_Part_C__Part_D_Universal_Audit_Guide_07_10_13 CLEAN--REDUCED [rev 11-13-2013 by OSORA PRA].pdf	Instruction
Attachment X - OEV Protocol Audit Process and Universe Request--REDUCED.pdf	Instruction
Attachment X - A - OEV Universe Template--REDUCED.pdf	Other-Template - OEV Universe
Attachment VIII - 2013 Audit Process Document--REDUCED.pdf	Instruction
Attachment VII-A - ODAG Universe Template --REDUCED.pdf	Other-Template - ODAG Universe
Attachment VII ODAG Audit Process and Universe Request--REDUCED.pdf	Instruction
Attachment I-B - FA Sample Case Minimum Documentation Required--REDUCED.pdf	Instruction
Attachment IX - SNP MOC Audit Process and Universe Request--REDUCED.pdf	Instruction
Attachment II-A - CDAG Universe Template--REDUCED.pdf	Other-Template - CDAG Universe
Attachment II - CDAG Audit Process and Universe Request--REDUCED.pdf	Instruction
Attachment I-A - FA Universe Template--REDUCED.pdf	Other-Template - FA Universe
Attachment I - FA Audit Process and Universe Request--REDUCED.pdf	Instruction
Att IX-A - SNP MOC Universe Template--REDUCED.pdf	Other-Template - SNP MOC Universe
4-2013 12-21-12-Attachment IV Organization Governance Template--REDUCED.pdf	Other-template - Organizational Stru
2-2013 12-21-12-Attachment III-A Sample Case File Documentation--REDUCED.pdf	Instruction
2.13.13 - 2013 CPE Attachment III -Data and Document Request [rev 7-21-13 by OSORA PRA]--REDUCED.pdf	Instruction
CMS-10191 Self Disclosure Report Attachment VI -Self Disclosure Report--REDUCED.pdf	Form
CMS-10191 CPE SELF-ASSESSMENT QUESTIONNAIRE 5-2013 12-21-12-Attachment V - CPE Self-Assessment Questionnaire--REDUCED.pdf	Form
CMS-10191 Key Contacts for Compliance Program Operations 3-2013 12-21-12-Attachment III-B Compliance Program Contacts--REDUCED.pdf	Form
PRA - Crosswalk - Protocol 2012- 2013 changes v2--REDUCED.PDF PRA - Crosswalk - Protocol 2012- 2013 changes v2--REDUCED	IC Document
PRA - Crosswalk - Engagement Letter CLEAN 7_9_13--REDUCED.pdf PRA - Crosswalk - Engagement Letter CLEAN 7_9_13--REDUCED	IC Document
PRA - Crosswalk - Universal Audit Guide _07_02_13--REDUCED.pdf PRA - Crosswalk - Universal Audit Guide _07_02_13--REDUCED	IC Document
PRA - Crosswalk - Auidt Process CLEAN 7_10_13--REDUCED.pdf PRA - Crosswalk - Auidt Process CLEAN 7_10_13--REDUCED	IC Document
Appendix P - Engagement Letter_Start Notice-REDUCED.pdf Engagement Letter/Start Notice	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Medicare Parts C and D Universal Audit Guide

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.504 42 CFR 423.505 42 CFR 423.514

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
Instruction			Medicare_Part_C__Part_D_Universal_Audit_Guide_07_10_13 CLEAN--REDUCED [rev 11-13-2013 by OSORA PRA].pdf	Yes	No	Printable Only
Instruction			Attachment X - OEV Protocol Audit Process and Universe Request--REDUCED.pdf	Yes	No	Printable Only
Other-Template - OEV Universe			Attachment X - A - OEV Universe Template--REDUCED.pdf	Yes	Yes	Printable Only
Instruction			Attachment VIII - 2013 Audit Process Document--REDUCED.pdf	Yes	No	Printable Only
Other-Template - ODAG Universe			Attachment VII-A - ODAG Universe Template --REDUCED.pdf	Yes	Yes	Fillable Printable
Instruction			Attachment VII ODAG Audit Process and Universe Request--REDUCED.pdf	Yes	No	Printable Only
Form	CMS-10191	Self Disclosure Report	Attachment VI -Self Disclosure Report--REDUCED.pdf	Yes	Yes	Fillable Printable
Instruction			Attachment I-B - FA Sample Case Minimum Documentation Required--REDUCED.pdf	Yes	No	Printable Only
Instruction			Attachment IX - SNP MOC Audit Process and Universe Request--REDUCED.pdf	Yes	No	Printable Only
Other-Template - CDAG Universe			Attachment II-A - CDAG Universe Template--REDUCED.pdf	Yes	Yes	Printable Only
Instruction			Attachment II - CDAG Audit Process and Universe Request--REDUCED.pdf	Yes	No	Printable Only
Other-Template - FA Universe			Attachment I-A - FA Universe Template--REDUCED.pdf	Yes	Yes	Printable Only
Instruction			Attachment I - FA Audit Process and Universe Request--REDUCED.pdf	Yes	No	Printable Only
Other-Template - SNP MOC Universe			Att IX-A - SNP MOC Universe Template--REDUCED.pdf	Yes	Yes	Printable Only
Form	CMS-10191	CPE SELF-ASSESSMENT QUESTIONNAIRE	5-2013 12-21-12-Attachment V - CPE Self-Assessment Questionnaire--REDUCED.pdf	Yes	Yes	Fillable Printable
Other-template - Organizational Structure and Governance			4-2013 12-21-12-Attachment IV Organization Governance Template--REDUCED.pdf	Yes	No	Printable Only
Form	CMS-10191	Key Contacts for Compliance Program Operations	3-2013 12-21-12-Attachment III-B Compliance Program Contacts--REDUCED.pdf	Yes	Yes	Fillable Printable
Instruction			2-2013 12-21-12-Attachment III-A Sample Case File Documentation--REDUCED.pdf	Yes	No	Printable Only
Instruction			2.13.13 - 2013 CPE Attachment III -Data and Document Request [rev 7-21-13 by OSORA PRA]--REDUCED.pdf	Yes	No	Printable Only

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: 195

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: 90 %

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	195	0	195
Annual IC Time Burden (Hours)	23,595	-585	24,180
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
PRA - Crosswalk - Protocol 2012- 2013 changes v2--REDUCED	PRA - Crosswalk - Protocol 2012- 2013 changes v2--REDUCED.PDF	07/24/2013
PRA - Crosswalk - Engagement Letter CLEAN 7_9_13--REDUCED	PRA - Crosswalk - Engagement Letter CLEAN 7_9_13--REDUCED.pdf	07/24/2013
PRA - Crosswalk - Universal Audit Guide _07_02_13--REDUCED	PRA - Crosswalk - Universal Audit Guide _07_02_13--REDUCED.pdf	07/24/2013
PRA - Crosswalk - Auidt Process CLEAN 7_10_13--REDUCED	PRA - Crosswalk - Auidt Process CLEAN 7_10_13--REDUCED.pdf	07/24/2013
Engagement Letter/Start Notice	Appendix P - Engagement Letter_Start Notice-REDUCED.pdf	07/24/2013

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