Form CMS-10495 Assumptions

Registration, Attestation, Dispute Resolution and Correction, Assumptions Document and Data Retention Requirements for Open Payments (CMS-10495)

CMS-10495 - Attestation and Assumptions Screen Shots

AM and Applicable GPO (Assumptions Document)

OMB: 0938-1237

Document [pdf]
Download: pdf | pdf
OMB Control No: 0938-1237
Expiration Date: XX/2020

Screen Shots Submission Flow
The screen shots below illustrate the workflow (submission + Attestation) of a user uploading a file
containing general payments records.
File Upload-General Payments

[Type here]
Select criteria for file upload

Successful File Upload

2

[Type here]
Payments passed file level validation check and ready for FINAL Submission

Final Submission Button Enabled for final Submission

3

[Type here]

Final Submission Confirmation

Post Final Submission Confirmation

4

[Type here]
Begin Attestation

Attestation-Confirm Payments

5

[Type here]
Add Assumptions Yes/No?

Add Assumptions- Yes workflow

6

[Type here]
Assumptions Added

Agree To Attestation

7

[Type here]
Agree to Attestation_Cont

Agree to Attestation_Cont

8

[Type here]
Review and Attest

Review and Attest

9

[Type here]
Records shown as attested

10


File Typeapplication/pdf
AuthorBirgach, Elmehdi
File Modified2017-02-27
File Created2017-02-27

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