Information Collection

Medicare Part C and Part D Data Validation (42 C.F.R. 422.516g and 423.514g) - (CMS-10305)

IC 194762 under ICR 201311-0938-014 · OMB 0938-1115.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1115 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
App1DataValStandards (2).docx	Instruction
App3DataExtractSamplInst.docx	Instruction
App4_Instructions for FDCF.doc	Instruction
CMS-10305 Appendix 2: Organizational Assessment Instrument App2OrgAssessmentInst1.docx	Form and Instruction
CMS-10305 Appendix 5: Data Collection Form App5FdgsDataCollectForm.xlsx	Form
Crosswalk.CMS_10305.xlsx Crosswalk	IC Document

IC Title:

Medicare Part C and Part D Data Validation (42 C.F.R. 422.516g and 423.514g) - (CMS-10305)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.516_(a)(1),(a)(2) 42 CFR 422.516(a)(3),(a)(4),(a)(6) 42 CFR 423.514 (a)(1) (a) (2) 42 CFR 423.514 (a)(3) (a) (4) (a) (6)

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			App1DataValStandards (2).docx	Yes	No	Printable Only
Form and Instruction	CMS-10305	Appendix 2: Organizational Assessment Instrument	App2OrgAssessmentInst1.docx	Yes	Yes	Fillable Printable
Instruction			App3DataExtractSamplInst.docx	Yes	No	Printable Only
Instruction			App4_Instructions for FDCF.doc	Yes	No	Printable Only
Form	CMS-10305	Appendix 5: Data Collection Form	App5FdgsDataCollectForm.xlsx	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 657

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	657	0	23	634
Annual IC Time Burden (Hours)	179,301	-55,802	-2,024	237,127
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	Crosswalk.CMS_10305.xlsx	11/13/2013

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