Information Collection

2019 029 Noridian Feedback Survey_Enrollment (2) 30628

IC 236150 under ICR 201805-1090-003 · OMB 1090-0008.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1090-0008 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 029 2019 029 Noridian Feedback Survey_Enrollment (2) 30628	Form and Instruction
029 2019 029 Noridian Feedback Survey_Enrollment (2) 30628 2019 029 Noridian Feedback Survey_Enrollment (2) 30628.xlsx	Form and Instruction
029 Noridian Feedback Survey_MR AB 30628 Noridian Feedback Survey_MR AB 30628.xlsx	Form and Instruction
029 Noridian Feedback Survey_MR DME PA 30628 Noridian Feedback Survey_MR DME PA 30628.xlsx	Form and Instruction
029 Noridian Feedback Survey_MR DME TPE (1) 30628 Noridian Feedback Survey_MR DME TPE (1) 30628.xlsx	Form and Instruction
029 Noridian Feedback Survey_PCC 30628 Noridian Feedback Survey_PCC 30628.xlsx	Form and Instruction
029 Noridian Feedback Survey_POE Events 30628 Noridian Feedback Survey_POE Events 30628.xlsx	Form and Instruction
029 Noridian Feedback Survey_POE Page 30628 Noridian Feedback Survey_POE Page 30628.xlsx	Form and Instruction
029 Noridian Feedback Survey_Recoup 30628 Noridian Feedback Survey_Recoup 30628.xlsx	Form and Instruction
029 Noridian Feedback Survey_Redeter (1) 30628 Noridian Feedback Survey_Redeter (1) 30628.xlsx	Form and Instruction
1090-0008 Generic Clearance Request Form_CMS Survey_IA 30628 Amend 4.pdf 1090-0008 Generic Clearance Request Form_CMS Survey_IA 30628 Amend 4	IC Document
Noridian Enrollment Feedback Survey 30628.docx Noridian Enrollment Feedback Survey 30628	IC Document
Noridian Medical Review AB Feedback Survey 30628.docx Noridian Medical Review AB Feedback Survey 30628	IC Document
Noridian Medical Review Prior Authorization Feedback Survey 30628.docx Noridian Medical Review Prior Authorization Feedback Survey 30628	IC Document
Noridian Recoupment Feedback Survey 30628.docx Noridian Recoupment Feedback Survey 30628	IC Document
Noridian Redeterminations Feedback Survey 30628.docx Noridian Redeterminations Feedback Survey 30628	IC Document
Noridian Webpage Specific Feedback Survey 30628.docx Noridian Webpage Specific Feedback Survey 30628	IC Document
Noridian Medical Review Targeted Probe & Educate DME Feedback Survey 30628.docx Noridian Medical Review Targeted Probe & Educate DME Feedback Survey 30628	IC Document
Noridian Provider Contact Center Feedback Survey 30628.docx Noridian Provider Contact Center Feedback Survey 30628	IC Document
Noridian Provider Outreach & Education Schedule of Events Feedback Survey 30628.docx Noridian Provider Outreach & Education Schedule of Events Feedback Survey 30628	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

2019 029 Noridian Feedback Survey_Enrollment (2) 30628

Agency IC Tracking Number:

029

IC Status: New

Obligation to Respond: Voluntary

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
Form and Instruction	029	2019 029 Noridian Feedback Survey_Enrollment (2) 30628	2019 029 Noridian Feedback Survey_Enrollment (2) 30628.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	029	Noridian Feedback Survey_MR AB 30628	Noridian Feedback Survey_MR AB 30628.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	029	Noridian Feedback Survey_MR DME PA 30628	Noridian Feedback Survey_MR DME PA 30628.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	029	Noridian Feedback Survey_MR DME TPE (1) 30628	Noridian Feedback Survey_MR DME TPE (1) 30628.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	029	Noridian Feedback Survey_PCC 30628	Noridian Feedback Survey_PCC 30628.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	029	Noridian Feedback Survey_POE Events 30628	Noridian Feedback Survey_POE Events 30628.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	029	Noridian Feedback Survey_POE Page 30628	Noridian Feedback Survey_POE Page 30628.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	029	Noridian Feedback Survey_Recoup 30628	Noridian Feedback Survey_Recoup 30628.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	029	Noridian Feedback Survey_Redeter (1) 30628	Noridian Feedback Survey_Redeter (1) 30628.xlsx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,600

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	3,600	3,600
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
1090-0008 Generic Clearance Request Form_CMS Survey_IA 30628 Amend 4	1090-0008 Generic Clearance Request Form_CMS Survey_IA 30628 Amend 4.pdf	05/21/2019
Noridian Enrollment Feedback Survey 30628	Noridian Enrollment Feedback Survey 30628.docx	05/21/2019
Noridian Medical Review AB Feedback Survey 30628	Noridian Medical Review AB Feedback Survey 30628.docx	05/21/2019
Noridian Medical Review Prior Authorization Feedback Survey 30628	Noridian Medical Review Prior Authorization Feedback Survey 30628.docx	05/21/2019
Noridian Recoupment Feedback Survey 30628	Noridian Recoupment Feedback Survey 30628.docx	05/21/2019
Noridian Redeterminations Feedback Survey 30628	Noridian Redeterminations Feedback Survey 30628.docx	05/21/2019
Noridian Webpage Specific Feedback Survey 30628	Noridian Webpage Specific Feedback Survey 30628.docx	05/21/2019
Noridian Medical Review Targeted Probe & Educate DME Feedback Survey 30628	Noridian Medical Review Targeted Probe & Educate DME Feedback Survey 30628.docx	05/21/2019
Noridian Provider Contact Center Feedback Survey 30628	Noridian Provider Contact Center Feedback Survey 30628.docx	05/21/2019
Noridian Provider Outreach & Education Schedule of Events Feedback Survey 30628	Noridian Provider Outreach & Education Schedule of Events Feedback Survey 30628.docx	05/21/2019

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