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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.