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 201409-0938-014 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Appendix1 CMS_10305_DV_V5_090914_revised.pdf	Instruction
App4_Instructions for FDCF v5 090914.pdf	Instruction
Appendix3V5 110614.v2.docx	Instruction
CMS-10305 Appendix 2: Organizational Assessment Instrument App2 OrgAssessment_CMS_10305_V5 110614.docx	Form and Instruction
CMS-10305 Appendix 5: Findings Data Collection Form Appendix5V5 FDCF102814.xlsx	Form and Instruction
Crosswalk 091014docx.pdf Crosswalk	IC Document
CMS-10305 - Supplemental Crosswalk 30 Day Internal Review rev 11-6-2014 v4 by OSORA PRA.docx Supplemental Crosswalk (30-day Internal CMS Review)	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)(3),(a)(4),(a)(6) 42 CFR 422.516_(a)(1),(a)(2) 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			Appendix1 CMS_10305_DV_V5_090914_revised.pdf	Yes	No	Printable Only
Instruction			App4_Instructions for FDCF v5 090914.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10305	Appendix 2: Organizational Assessment Instrument	App2 OrgAssessment_CMS_10305_V5 110614.docx	Yes	Yes	Fillable Printable
Instruction			Appendix3V5 110614.v2.docx	Yes	No	Printable Only
Form and Instruction	CMS-10305	Appendix 5: Findings Data Collection Form	Appendix5V5 FDCF102814.xlsx	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 214

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	Previously Approved
Annual Number of Responses for this IC	706	49	657
Annual IC Time Burden (Hours)	202,578	23,277	179,301
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	Crosswalk 091014docx.pdf	09/24/2014
Supplemental Crosswalk (30-day Internal CMS Review)	CMS-10305 - Supplemental Crosswalk 30 Day Internal Review rev 11-6-2014 v4 by OSORA PRA.docx	11/17/2014

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