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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
Document Name
Document Type
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
IC Document
Information Collection (IC) Details

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External Quality Review of Medicaid MCOs and Supporting Regulations in 42 CFR 438.360, 438.362, and 438.364
 
No Modified
 
Mandatory
 
42 CFR 438.362 42 CFR 438.364 42 CFR 438.360

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction Introduction to Protocols 051712.pdf Yes Yes Fillable Printable
Instruction P1 - Compliance Review 05172012.pdf Yes Yes Fillable Printable
Instruction P1 Attachment A - Compliance Review Worksheet 122111edit (3).pdf Yes Yes Fillable Printable
Instruction P1 Attachment B - Compliance definitions 122111.pdf - Adobe Acrobat Pro.pdf Yes Yes Fillable Printable
Instruction P1 Attachment C - Sample Site Visit Agenda 122111.pdf Yes Yes Fillable Printable
Instruction P1Attach D_ Compliance_InterQ 05172012.pdf Yes Yes Fillable Printable
Instruction P2 - Validation of Measures 051112.pdf Yes Yes Fillable Printable
Instruction P2 Attachment A - PM Validation Worksheet 122111.pdf Yes Yes Fillable Printable
Instruction P3 - PIP Validation 051712.pdf Yes Yes Fillable Printable
Instruction P3 Attachment A - PIP worksheet 5-22-12.pdf Yes Yes Fillable Printable
Instruction P4 - Validate Enounter Data 05-17-2012.pdf Yes Yes Fillable Printable
Instruction P4 Attachment A - Encounter Data Tables 122111 (4).pdf Yes Yes Fillable Printable
Instruction P4 Attachment B - Medical Record Review Worksheet 122111.pdf Yes Yes Fillable Printable
Instruction P5 - Surveys 051712.pdf Yes Yes Fillable Printable
Instruction P5 Attachment A - Survey Validation Worksheet 050712.pdf Yes Yes Fillable Printable
Instruction P6- PM Validation 011212.pdf Yes Yes Fillable Printable
Instruction P6 Attachment A - PM Calculation Tables 122111 (2).pdf Yes Yes Fillable Printable
Instruction P7 - PIP Implementation 051012.pdf Yes Yes Fillable Printable
Instruction P8 - Focused Studies 011212.pdf Yes Yes Fillable Printable
Instruction Appendix I - Methodology 011212.pdf Yes Yes Fillable Printable
Instruction Appendix II - Sampling Approaches 122111.pdf Yes Yes Fillable Printable
Instruction Appendix III - Glossary 122111.pdf Yes Yes Fillable Printable
Instruction Appendix IV - Acronyms 122111.pdf Yes Yes Fillable Printable
Instruction Appendix V - IS Assessment 057712 formatted.pdf Yes Yes Fillable Printable
Instruction Appendix V Attachment A - ISCA tool 011212 (2).pdf Yes Yes Fillable Printable
Instruction Appendix V Attachment B - IS Review 011212.pdf Yes Yes Fillable Printable

Health Health Care Services

 

43 0
   
State, Local, and Tribal Governments
 
   100 %

  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

Title Document Date Uploaded
Protocol Changes 5-11-12 Final Edits to EQR Draft Protocols based on Public Comments.docx 06/13/2012
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.