Information Collection

Medicare Parts C and D Program Audit Protocols and Data Requests

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

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form CMS-10191
CPE Program Area Audit Process and Data Request Medicare Parts C and D Program Audit Protocols and Data Requests
Form and Instruction
Form CMS-10191
CPE Self-Assessment Questionnaire Medicare Parts C and D Program Audit Protocols and Data Requests
Form and Instruction
Form CMS-10191
CPE Compliance Officer Questionnaire Medicare Parts C and D Program Audit Protocols and Data Requests
Form and Instruction
Form CMS-10191
CPE Audit Organizational Structure and Governance PPT Template Medicare Parts C and D Program Audit Protocols and Data Requests
Form and Instruction
Form CMS-10191
Accountability for Oversight of First-Tier, Downstream and Related Entities Questionnaire Medicare Parts C and D Program Audit Protocols and Data Requests
Form and Instruction
Form CMS-10191
SIU/FWA Prevention and Detection Questionnaire Medicare Parts C and D Program Audit Protocols and Data Requests
Form and Instruction
Form CMS-10191
FA AUDIT PROCESS AND DATA REQUEST Medicare Parts C and D Program Audit Protocols and Data Requests
Form and Instruction
Form CMS-10191
CDAG AUDIT PROCESS AND DATA REQUEST Medicare Parts C and D Program Audit Protocols and Data Requests
Form and Instruction
Form CMS-10191
CDAG Supplemental Questions Medicare Parts C and D Program Audit Protocols and Data Requests
Form
Form CMS-10191
ODAG AUDIT PROCESS AND DATA REQUEST Medicare Parts C and D Program Audit Protocols and Data Requests
Form and Instruction
Form CMS-10191
ODAG Supplemental Questions Medicare Parts C and D Program Audit Protocols and Data Requests
Form
Form CMS-10191
SNP-MOC AUDIT PROCESS AND DATA REQUEST Medicare Parts C and D Program Audit Protocols and Data Requests
Form and Instruction
Form CMS-10191
MTM PILOT AUDIT PROCESS AND DATA REQUEST Medicare Parts C and D Program Audit Protocols and Data Requests
Form and Instruction
Form CMS-10191
CDAG CDM Impact Analysis Medicare Parts C and D Program Audit Protocols and Data Requests
Form
Form CMS-10191
CDAG GRV Impact Analysis Medicare Parts C and D Program Audit Protocols and Data Requests
Form
Form CMS-10191
FA Impact Analysis Medicare Parts C and D Program Audit Protocols and Data Requests
Form
Form CMS10191
MTM Impact Analysis Medicare Parts C and D Program Audit Protocols and Data Requests
Form
Form CMS-10191
ODAG CDM Impact Analysis Medicare Parts C and D Program Audit Protocols and Data Requests
Form
Form CMS-10191
ODAG DIS Impact Analysis Medicare Parts C and D Program Audit Protocols and Data Requests
Form
Form CMS-10191
ODAG GRV Impact Analysis Medicare Parts C and D Program Audit Protocols and Data Requests
Form
Form CMS-10191
ODAG PMNT Impact Analysis Medicare Parts C and D Program Audit Protocols and Data Requests
Form
Form CMS-10191
SNP-MOC ICP ICT Impact Analysis Medicare Parts C and D Program Audit Protocols and Data Requests
Form
Form CMS-10191
SNP-MOC Impact Analysis Medicare Parts C and D Program Audit Protocols and Data Requests
Form
Form CMS-10191
SNP-MOC Training Impact Analysis Medicare Parts C and D Program Audit Protocols and Data Requests
Form
Form CMS-10191
Pre-Audit Issues Summary Medicare Parts C and D Program Audit Protocols and Data Requests
Form
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
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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
Form and Instruction CMS-10191 Yes Yes Fillable Fileable
Form and Instruction CMS-10191 Yes Yes Fillable Fileable
Form and Instruction CMS-10191 Yes Yes Fillable Fileable
Form and Instruction CMS-10191 Yes Yes Fillable Fileable
Form and Instruction CMS-10191 Yes Yes Fillable Fileable
Form and Instruction CMS-10191 Yes Yes Fillable Fileable
Form and Instruction CMS-10191 Yes Yes Fillable Fileable
Form and Instruction CMS-10191 Yes Yes Fillable Fileable
Form CMS-10191 Yes Yes Fillable Fileable
Form and Instruction CMS-10191 Yes Yes Fillable Fileable
Form CMS-10191 Yes Yes Fillable Fileable
Form and Instruction CMS-10191 Yes Yes Fillable Fileable
Form and Instruction CMS-10191 Yes Yes Fillable Fileable
Form CMS-10191 Yes Yes Fillable Fileable
Form CMS-10191 Yes Yes Fillable Fileable
Form CMS-10191 Yes Yes Fillable Fileable
Form CMS10191 Yes Yes Fillable Fileable
Form CMS-10191 Yes Yes Fillable Fileable
Form CMS-10191 Yes Yes Fillable Fileable
Form CMS-10191 Yes Yes Fillable Fileable
Form CMS-10191 Yes Yes Fillable Fileable
Form CMS-10191 Yes Yes Fillable Fileable
Form CMS-10191 Yes Yes Fillable Fileable
Form CMS-10191 Yes Yes Fillable Fileable
Form CMS-10191 Yes Yes Fillable Fileable

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 241 0 46 0 0 195
Annual IC Time Burden (Hours) 52,261 0 28,666 0 0 23,595
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
Crosswalk 12/09/2016
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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