Information Collection

Medicare Parts C and D Program Audit Protocols and Data Requests

IC 43683 under ICR 201612-0938-003 · OMB 0938-1000.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1000 can be found here:

2020-01-07 - Revision of a currently approved collection

Documents and Forms

Document Name Document Type
Form CMS-10191 Medicare Parts C and D Program Audit Protocols and Data Requests Form and Instruction
CMS-10191 CPE Program Area Audit Process and Data Request Attachment_I_CPE_AuditProcess_DataRequest.pdf Form and Instruction
CMS-10191 CPE Self-Assessment Questionnaire Attachment_I-A_CPE_Self-Assessment_Questionnaire_SA-Q.pdf Form and Instruction
CMS-10191 CPE Compliance Officer Questionnaire Attachment_I-B_CPE_Compliance _Officer_Questionnaire_CO-Q.pdf Form and Instruction
CMS-10191 CPE Audit Organizational Structure and Governance PPT Te Attachment_I-C_CPE_Organizational_Structure_Governance _PPT_ Template.pdf Form and Instruction
CMS-10191 Accountability for Oversight of First-Tier, Downstream a Attachment_I-D_CPE_FDR_Oversight_Questionnaire_FDR-Q.pdf Form and Instruction
CMS-10191 SIU/FWA Prevention and Detection Questionnaire Attachment_I-E_CPE_SIU_FWA_Questionnaire_FWA-Q.pdf Form and Instruction
CMS-10191 FA AUDIT PROCESS AND DATA REQUEST Attachment_II_FA_AuditProcess_DataRequest.pdf Form and Instruction
CMS-10191 CDAG AUDIT PROCESS AND DATA REQUEST Attachment_III_CDAG_AuditProcess_DataRequest (2).pdf Form and Instruction
CMS-10191 CDAG Supplemental Questions Attachment_III-A_CDAG_SupplementalQuestions.pdf Form
CMS-10191 ODAG AUDIT PROCESS AND DATA REQUEST Attachment_IV_ODAG_AuditProcess_DataRequest.pdf Form and Instruction
CMS-10191 ODAG Supplemental Questions Attachment_IV-A_ODAG_SupplementalQuestionnaire.pdf Form
CMS-10191 SNP-MOC AUDIT PROCESS AND DATA REQUEST Attachment_V_SNP-MOC_AuditProcess_DataRequest.pdf Form and Instruction
CMS-10191 MTM PILOT AUDIT PROCESS AND DATA REQUEST Attachment_VI_MTM_AuditProcess_DataRequest.pdf Form and Instruction
CMS-10191 CDAG CDM Impact Analysis CDAG_CDM_Impact.pdf Form
CMS-10191 CDAG GRV Impact Analysis CDAG_GRV_Impact.pdf Form
CMS-10191 FA Impact Analysis FA_ImpactAnalysis_.pdf Form
CMS10191 MTM Impact Analysis MTM_ImpactAnalysis.pdf Form
CMS-10191 ODAG CDM Impact Analysis ODAG_CDM_Impact.pdf Form
CMS-10191 ODAG DIS Impact Analysis ODAG_DIS_Impact.pdf Form
CMS-10191 ODAG GRV Impact Analysis ODAG_GRV_Impact.pdf Form
CMS-10191 ODAG PMNT Impact Analysis ODAG_PMNT_Impact.pdf Form
CMS-10191 SNP-MOC ICP ICT Impact Analysis SNP-MOC_ICP_ICT_Impact.pdf Form
CMS-10191 SNP-MOC Impact Analysis SNP-MOC_Impact.pdf Form
CMS-10191 SNP-MOC Training Impact Analysis SNP-MOC_Training_Impact.pdf Form
CMS-10191 Pre-Audit Issues Summary Pre-AuditIssueSummary.pdf Form
Crosswalk_of_Revisions.pdf Crosswalk IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicare Parts C and D Program Audit Protocols and Data Requests	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.505 42 CFR 423.514 42 CFR 422.504

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10191	CPE Program Area Audit Process and Data Request	Attachment_I_CPE_AuditProcess_DataRequest.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10191	CPE Self-Assessment Questionnaire	Attachment_I-A_CPE_Self-Assessment_Questionnaire_SA-Q.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10191	CPE Compliance Officer Questionnaire	Attachment_I-B_CPE_Compliance _Officer_Questionnaire_CO-Q.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10191	CPE Audit Organizational Structure and Governance PPT Template	Attachment_I-C_CPE_Organizational_Structure_Governance _PPT_ Template.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10191	Accountability for Oversight of First-Tier, Downstream and Related Entities Questionnaire	Attachment_I-D_CPE_FDR_Oversight_Questionnaire_FDR-Q.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10191	SIU/FWA Prevention and Detection Questionnaire	Attachment_I-E_CPE_SIU_FWA_Questionnaire_FWA-Q.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10191	FA AUDIT PROCESS AND DATA REQUEST	Attachment_II_FA_AuditProcess_DataRequest.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10191	CDAG AUDIT PROCESS AND DATA REQUEST	Attachment_III_CDAG_AuditProcess_DataRequest (2).pdf	Yes	Yes	Fillable Fileable
Form	CMS-10191	CDAG Supplemental Questions	Attachment_III-A_CDAG_SupplementalQuestions.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10191	ODAG AUDIT PROCESS AND DATA REQUEST	Attachment_IV_ODAG_AuditProcess_DataRequest.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10191	ODAG Supplemental Questions	Attachment_IV-A_ODAG_SupplementalQuestionnaire.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10191	SNP-MOC AUDIT PROCESS AND DATA REQUEST	Attachment_V_SNP-MOC_AuditProcess_DataRequest.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10191	MTM PILOT AUDIT PROCESS AND DATA REQUEST	Attachment_VI_MTM_AuditProcess_DataRequest.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10191	CDAG CDM Impact Analysis	CDAG_CDM_Impact.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10191	CDAG GRV Impact Analysis	CDAG_GRV_Impact.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10191	FA Impact Analysis	FA_ImpactAnalysis_.pdf	Yes	Yes	Fillable Fileable
Form	CMS10191	MTM Impact Analysis	MTM_ImpactAnalysis.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10191	ODAG CDM Impact Analysis	ODAG_CDM_Impact.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10191	ODAG DIS Impact Analysis	ODAG_DIS_Impact.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10191	ODAG GRV Impact Analysis	ODAG_GRV_Impact.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10191	ODAG PMNT Impact Analysis	ODAG_PMNT_Impact.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10191	SNP-MOC ICP ICT Impact Analysis	SNP-MOC_ICP_ICT_Impact.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10191	SNP-MOC Impact Analysis	SNP-MOC_Impact.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10191	SNP-MOC Training Impact Analysis	SNP-MOC_Training_Impact.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10191	Pre-Audit Issues Summary	Pre-AuditIssueSummary.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: 201	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	241	46	195
Annual IC Time Burden (Hours)	52,261	28,666	23,595
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Crosswalk_of_Revisions.pdf	12/09/2016

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