Information Collection

QHP Certification

IC 206068 under ICR 201409-0938-005 · OMB 0938-1187.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1187 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10433 Network ID QHP Certification	Form
Form CMS-10433 Data Template Administrative QHP Certification	Form
Form CMS-10433 Medical Essential Community Providers QHP Certification	Form
Form CMS-10433 Dental Essential Community Provider QHP Certification	Form
Form CMS-10433 URAC Application QHP Certification	Form
Form CMS-10433 NCQA Template QHP Certification	Form
Form CMS-10433 AAAHC QHP Certification	Form
Form CMS-10433 Network Adequacy QHP Certification	Form
Form CMS-10433 Program Attestations QHP Certification	Form
Form CMS-10433 Accreditation Attestations QHP Certification	Form
Form CMS-10433 Plan and Benefit QHP Certification	Form
Form CMS-10433 Prescription Drugs Template QHP Certification	Form
Form CMS-10433 Service Area QHP Certification	Form
Form CMS-10433 Rates Table QHP Certification	Form
Form CMS-10433 Business Rules QHP Certification	Form
CMS-10433_Appendix D RI RA Banking and Edge Server ( 7-23-14) clean(2).pdf	Instruction
CMS-10433 Data Template Administrative A1 Administrative.xlsm	Form
CMS-10433 Medical Essential Community Providers A2.1 Medical ECP.xlsm	Form
CMS-10433 Dental Essential Community Provider A2.2 Dental ECP.xlsm	Form
CMS-10433 URAC Application A3.1 URAC.xlsm	Form
CMS-10433 NCQA Template A3.2 NCQA.xlsm	Form
CMS-10433 AAAHC A3.3 AAAHC.xlsm	Form
CMS-10433 Network Adequacy A4 NetworkAdequacy.xlsm	Form
CMS-10433 Program Attestations A5 Program Attestations.pdf	Form
CMS-10433 Accreditation Attestations A6 Accreditation Attestation.pdf	Form
CMS-10433 Plan and Benefit B1 Plan and Benefits.xlsm	Form
CMS-10433 Prescription Drugs Template B2 Prescription_Drugs_Template.xlsm	Form
CMS-10433 Service Area B3 ServiceArea.xlsm	Form
CMS-10433 Network ID B4 NetworkID.xlsm	Form
CMS-10433 Rates Table C1 RatesTable.xlsm	Form
CMS-10433 Business Rules C2 Business Rules.xlsm	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

QHP Certification

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.1065 45 CFR 156.200

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	CMS-10433	Network ID	B4 NetworkID.xlsm	Yes	Yes	Fillable Fileable
Form	CMS-10433	Rates Table	C1 RatesTable.xlsm	Yes	Yes	Fillable Fileable
Form	CMS-10433	Business Rules	C2 Business Rules.xlsm	Yes	Yes	Fillable Fileable
Form	CMS-10433	Data Template Administrative	A1 Administrative.xlsm	Yes	Yes	Fillable Fileable
Form	CMS-10433	Medical Essential Community Providers	A2.1 Medical ECP.xlsm	Yes	Yes	Fillable Fileable
Form	CMS-10433	Dental Essential Community Provider	A2.2 Dental ECP.xlsm	Yes	Yes	Fillable Fileable
Form	CMS-10433	URAC Application	A3.1 URAC.xlsm	Yes	Yes	Fillable Fileable
Form	CMS-10433	NCQA Template	A3.2 NCQA.xlsm	Yes	Yes	Fillable Fileable
Form	CMS-10433	AAAHC	A3.3 AAAHC.xlsm	Yes	Yes	Fillable Fileable
Form	CMS-10433	Network Adequacy	A4 NetworkAdequacy.xlsm	Yes	Yes	Fillable Fileable
Form	CMS-10433	Program Attestations	A5 Program Attestations.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10433	Accreditation Attestations	A6 Accreditation Attestation.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10433	Plan and Benefit	B1 Plan and Benefits.xlsm	Yes	Yes	Fillable Fileable
Form	CMS-10433	Prescription Drugs Template	B2 Prescription_Drugs_Template.xlsm	Yes	Yes	Fillable Fileable
Form	CMS-10433	Service Area	B3 ServiceArea.xlsm	Yes	Yes	Fillable Fileable
Instruction			CMS-10433_Appendix D RI RA Banking and Edge Server ( 7-23-14) clean(2).pdf	Yes	Yes	Fillable Fileable

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: 975

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	975	975
Annual IC Time Burden (Hours)	182,325	182,325
Annual IC Cost Burden (Dollars)	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.