Information Collection

Trial Year and Routine Audits

IC 225129 under ICR 201612-0938-020 · OMB 0938-1327.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1327 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10630 Trial Year and Routine Audits	Form
CMS-10630 PACE Audit Process and Data Request Protocol PACE_AuditProcess_DataRequest.pdf	Form and Instruction
CMS-10630 PACE Supplemental Questions Attachment II-PACE_SupplementalQuestions.pdf	Form
CMS-10630 Pre-Audit Issue Summary Attachment_III_Pre-AuditIssueSummary.pdf	Form
CMS-10630 Service Delivery Impact Analysis Template Service_Delivery_IA_Template.pdf	Form
CMS-10630 Appeals Impact Analysis Template Appeal_IA_Template.pdf	Form
CMS-10630 Grievances Impact Analysis Template Grievance_IA_Template.pdf	Form
CMS-10630 Root Cause Analysis Template Root_Cause_Template.pdf	Form
CMS-10630 Clinical Appropriateness for Comprehensive Care Impact A Clinical_Approp_IA_Template_comp.care.pdf	Form
CMS-10630 Clinical Appropriateness for Emergencies Impact Analysis Clinical_Approp_IA_Template_emergency.pdf	Form
CMS-10630 Clinical Appropriateness for IDT Documentation Impact An Clinical_Approp_IA_Template_IDT_doc.pdf	Form
CMS-10630 Clinical Appropriateness for Medical Record Documentatio Clinical_Approp_IA_Template_Med_Rec_Doc.pdf	Form
CMS-10630 Clinical Appropriateness for Restraints Impact Analysis Clinical_Approp_IA_Template_restraints.pdf	Form
CMS-10630 Clinical Appropriateness for Care Planning Impact Analys Clinical_Approp_IA_Template_Care_Plan.pdf	Form
CMS-10630 Clinical Appropriateness for Assessments Impact Analysis Clinical_Approp_IA_Template_Assessments.pdf	Form
CMS-10630 Clinical Appropriateness for Infections Impact Analysis Clinical_Approp_IA_Template_Infections.pdf	Form
CMS-10630 Clinical Appropriateness for Providers Impact Analysis T Clinical_Approp_IA_Template_Providers.pdf	Form
CMS-10630 Clinical Appropriateness for Transportation Impact Analy Clinical_Approp_IA Template_Transportation.pdf	Form
CMS-10630 Personnel Impact Analysis Template Personnel_IA_Template.pdf	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Trial Year and Routine Audits

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 460.190 42 CFR 460.192

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
Form	CMS-10630	Clinical Appropriateness for IDT Documentation Impact Analysis Template	Clinical_Approp_IA_Template_IDT_doc.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Clinical Appropriateness for Providers Impact Analysis Template	Clinical_Approp_IA_Template_Providers.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10630	PACE Audit Process and Data Request Protocol	PACE_AuditProcess_DataRequest.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	PACE Supplemental Questions	Attachment II-PACE_SupplementalQuestions.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Pre-Audit Issue Summary	Attachment_III_Pre-AuditIssueSummary.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Service Delivery Impact Analysis Template	Service_Delivery_IA_Template.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Appeals Impact Analysis Template	Appeal_IA_Template.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Grievances Impact Analysis Template	Grievance_IA_Template.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Root Cause Analysis Template	Root_Cause_Template.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Clinical Appropriateness for Comprehensive Care Impact Analysis Template	Clinical_Approp_IA_Template_comp.care.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Clinical Appropriateness for Emergencies Impact Analysis Template	Clinical_Approp_IA_Template_emergency.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Clinical Appropriateness for Medical Record Documentation Impact Analysis Template	Clinical_Approp_IA_Template_Med_Rec_Doc.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Clinical Appropriateness for Restraints Impact Analysis Template	Clinical_Approp_IA_Template_restraints.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Clinical Appropriateness for Care Planning Impact Analysis Template	Clinical_Approp_IA_Template_Care_Plan.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Clinical Appropriateness for Assessments Impact Analysis Template	Clinical_Approp_IA_Template_Assessments.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Clinical Appropriateness for Infections Impact Analysis Template	Clinical_Approp_IA_Template_Infections.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Clinical Appropriateness for Transportation Impact Analysis Template	Clinical_Approp_IA Template_Transportation.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Personnel Impact Analysis Template	Personnel_IA_Template.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: 119

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	72	72
Annual IC Time Burden (Hours)	17,280	17,280
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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