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Federal forms, ICRs, and supporting documents

Information Collection

External Quality Review of Medicaid MCOs and Supporting Regulations in 42 CFR 438.360, 438.362, and 438.364

IC 8551 under ICR 201504-0938-009 · OMB 0938-0786.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Introduction to Protocols 051712.pdf Instruction
P1 - Compliance Review 05172012.pdf Instruction
P1 Attachment A - Compliance Review Worksheet 122111edit (3).pdf Instruction
P1 Attachment B - Compliance definitions 122111.pdf - Adobe Acrobat Pro.pdf Instruction
P1 Attachment C - Sample Site Visit Agenda 122111.pdf Instruction
P1Attach D_ Compliance_InterQ 05172012.pdf Instruction
P2 - Validation of Measures 051112.pdf Instruction
P2 Attachment A - PM Validation Worksheet 122111.pdf Instruction
P3 - PIP Validation 051712.pdf Instruction
P3 Attachment A - PIP worksheet 5-22-12.pdf Instruction
P4 - Validate Enounter Data 05-17-2012.pdf Instruction
P4 Attachment A - Encounter Data Tables 122111 (4).pdf Instruction
P4 Attachment B - Medical Record Review Worksheet 122111.pdf Instruction
P5 - Surveys 051712.pdf Instruction
P5 Attachment A - Survey Validation Worksheet 050712.pdf Instruction
P6- PM Validation 011212.pdf Instruction
P6 Attachment A - PM Calculation Tables 122111 (2).pdf Instruction
P7 - PIP Implementation 051012.pdf Instruction
P8 - Focused Studies 011212.pdf Instruction
Appendix I - Methodology 011212.pdf Instruction
Appendix II - Sampling Approaches 122111.pdf Instruction
Appendix III - Glossary 122111.pdf Instruction
Appendix IV - Acronyms 122111.pdf Instruction
Appendix V - IS Assessment 057712 formatted.pdf Instruction
Appendix V Attachment A - ISCA tool 011212 (2).pdf Instruction
Appendix V Attachment B - IS Review 011212.pdf Instruction
5-11-12 Final Edits to EQR Draft Protocols based on Public Comments.docx
Protocol Changes		IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

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
Instruction Yes Yes Fillable Printable
Instruction Yes Yes Fillable Printable
Instruction Yes Yes Fillable Printable
Instruction Yes Yes Fillable Printable
Instruction Yes Yes Fillable Printable
Instruction Yes Yes Fillable Printable
Instruction Yes Yes Fillable Printable
Instruction Yes Yes Fillable Printable
Instruction Yes Yes Fillable Printable
Instruction Yes Yes Fillable Printable
Instruction Yes Yes Fillable Printable
Instruction Yes Yes Fillable Printable
Instruction Yes Yes Fillable Printable
Instruction Yes Yes Fillable Printable
Instruction Yes Yes Fillable Printable
Instruction Yes Yes Fillable Printable
Instruction Yes Yes Fillable Printable
Instruction Yes Yes Fillable Printable
Instruction Yes Yes Fillable Printable
Instruction Yes Yes Fillable Printable
Instruction Yes Yes Fillable Printable
Instruction Yes Yes Fillable Printable
Instruction Yes Yes Fillable Printable
Instruction Yes Yes Fillable Printable
Instruction Yes Yes Fillable Printable
Instruction Yes Yes Fillable Printable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 76 0 0 6 0 70
Annual IC Time Burden (Hours) 451,288 0 0 35,645 0 415,643
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
Protocol Changes 06/13/2012
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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