Information Collection

Three-Year Network Adequacy Review for Medicare Advantage Organizations

IC 227912 under ICR 201708-0938-011 · OMB 0938-1346.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1346 can be found here:

Documents and Forms

Document Name Document Type
CY 2018 HSD Instructions_011017 - Final for 0938-New - 072417.pdf Instruction
NMM_OrgQuickReferenceUserGuide2.pdf Instruction
NoticeOfEntireNetworkReviewLetter - Final for 0938-New - 072417 (rev OSORA PRA).pdf Other-Notice of Network Review Lette
CMS-10636 Provider Table CY_2018 _Provider_HSD_Table_Final - Final for 0938-New - 072417.pdf Form
CMS-10636 Facility Table CY_2018_Facility_HSD_Table_Final - Final for 0938-New - 072417.pdf Form
CMS-10636 Exception Template CY_2018_MA_HSD_Exception_Request_Template - Final for 0938-New - 072417.pdf Form
CMS-10636 Justification Template CY_2018_Partial_County_Justification_Template - Final for 0938-New - 072417.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Three-Year Network Adequacy Review for Medicare Advantage Organizations	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CY 2018 HSD Instructions_011017 - Final for 0938-New - 072417.pdf	Yes	No	Printable Only
Form	CMS-10636	Provider Table	CY_2018 _Provider_HSD_Table_Final - Final for 0938-New - 072417.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10636	Facility Table	CY_2018_Facility_HSD_Table_Final - Final for 0938-New - 072417.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10636	Exception Template	CY_2018_MA_HSD_Exception_Request_Template - Final for 0938-New - 072417.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10636	Justification Template	CY_2018_Partial_County_Justification_Template - Final for 0938-New - 072417.pdf	Yes	Yes	Fillable Fileable
Instruction			NMM_OrgQuickReferenceUserGuide2.pdf	Yes	No	Printable Only
Other-Notice of Network Review Letter			NoticeOfEntireNetworkReviewLetter - Final for 0938-New - 072417 (rev OSORA PRA).pdf	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 304	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,652	1,652
Annual IC Time Burden (Hours)	15,692	15,692
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.