Information Collection

Chronic Care Improvement Program and Medicare Advantage Quality Improvement Project

IC 179877 under ICR 201404-0938-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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
2014 CCIP User Guide.pdf	Instruction
2014 QIP User Guide.pdf	Instruction
CMS-10209 CCIP Screen Shots - Act Section Annual Update.jpg CCIP Act Section Annual Update.jpg	Form
CMS-10209 CCIP Screen Shots - Contract Selection Screen Annual Upd CCIP Contract Selection Screen Annual Update.jpg	Form
CMS-10209 CCIP Screen Shots -- Do Section Annual Update CCIP Do Section Annual Update.jpg	Form
CMS-10209 CCIP Screen Shots -- Do Study Act Sections Annual Update CCIP Do Study Act Sections Annual Update.jpg	Form
CMS-10209 CCIP Screen Shots - Study Section Annual Update CCIP Study Section Annual Update.jpg	Form
CMS-10209 CCIP Screen Shots - Submission Selection Screen Annual U CCIP Submission Selection Screen Annual Update.jpg CCIP Screen Shots - Submission Selection Screen Annual Update	Form
CMS-10209 QIP Screen Shots - Act Section Annual Update QIP Act Section Annual Update.jpg	Form
CMS-10209 QIP Screen Shots - Contract Selection Screen Annual Upda QIP Contract Selection Screen Annual Update.jpg	Form
CMS-10209 QIP Screen Shots - Do Section Annual Update QIP Do Section Annual Update.jpg	Form
CMS-10209 QIP Screen Shots - Do Study Act Sections Annual Update QIP Do Study Act Sections Annual Update.jpg	Form
CMS-10209 QIP Screen Shots - Study Section Annual Update QIP Study Section Annual Update.jpg	Form
CMS-10209 QIP Screen Shots - Submission Screen Annual Update QIP Submission Screen Annual Update.jpg	Form
PRA_CCIP_User_Guides_Crosswalk.xlsx Crosswalk - CCIP User Guide	IC Document
PRA_QIP_User_Guides_Crosswalk.xlsx Crosswalk - QIP User Guide	IC Document

Information Collection (IC) Details

View Information Collection (IC)

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10209	CCIP Screen Shots -- Do Section Annual Update	CCIP Do Section Annual Update.jpg		Yes	Yes	Fillable Printable
Form	CMS-10209	CCIP Screen Shots -- Do Study Act Sections Annual Update	CCIP Do Study Act Sections Annual Update.jpg		Yes	Yes	Fillable Printable
Form	CMS-10209	CCIP Screen Shots - Study Section Annual Update	CCIP Study Section Annual Update.jpg		Yes	Yes	Fillable Printable
Form	CMS-10209	CCIP Screen Shots - Submission Selection Screen Annual Update	CCIP Submission Selection Screen Annual Update.jpg	CCIP Screen Shots - Submission Selection Screen Annual Update	Yes	Yes	Fillable Printable
Form	CMS-10209	QIP Screen Shots - Act Section Annual Update	QIP Act Section Annual Update.jpg		Yes	Yes	Fillable Printable
Form	CMS-10209	QIP Screen Shots - Contract Selection Screen Annual Update	QIP Contract Selection Screen Annual Update.jpg		Yes	Yes	Fillable Printable
Form	CMS-10209	QIP Screen Shots - Do Section Annual Update	QIP Do Section Annual Update.jpg		Yes	Yes	Fillable Printable
Form	CMS-10209	QIP Screen Shots - Do Study Act Sections Annual Update	QIP Do Study Act Sections Annual Update.jpg		Yes	Yes	Fillable Printable
Form	CMS-10209	QIP Screen Shots - Study Section Annual Update	QIP Study Section Annual Update.jpg		Yes	Yes	Fillable Printable
Form	CMS-10209	QIP Screen Shots - Submission Screen Annual Update	QIP Submission Screen Annual Update.jpg		Yes	Yes	Fillable Printable
Instruction			2014 CCIP User Guide.pdf		No		Printable Only
Instruction			2014 QIP User Guide.pdf		No		Paper Only
Form	CMS-10209	CCIP Screen Shots - Act Section Annual Update.jpg	CCIP Act Section Annual Update.jpg		Yes	Yes	Fillable Printable
Form	CMS-10209	CCIP Screen Shots - Contract Selection Screen Annual Update	CCIP Contract Selection Screen Annual Update.jpg		Yes	Yes	Fillable Printable

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: 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	Previously Approved
Annual Number of Responses for this IC	1,904	1,904
Annual IC Time Burden (Hours)	28,560	28,560
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk - CCIP User Guide	PRA_CCIP_User_Guides_Crosswalk.xlsx	04/07/2014
Crosswalk - QIP User Guide	PRA_QIP_User_Guides_Crosswalk.xlsx	04/07/2014

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