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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form CMS-10433 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:

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

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 %

	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

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.