Information Collection

Trial Year and Routine Audits

IC 225129 under ICR 201911-0938-013 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Clinical Appropriateness and Care Planning Impact Analys AlertIDT1P14.pdf	Form
CMS-10630 Appeals Impact Analysis Template AppealExt1P71.pdf	Form
CMS-10630 Appeals Impact Analysis Template Appeals1P651P661P681P73.pdf	Form
CMS-10630 Clinical Appropriateness and Care Planning Impact Analys Assessments1P491P501P82.pdf	Form
CMS-10630 Summary of any pre-audit issues AttachmentIIIPre-AuditIssueSummary.pdf	Form
CMS-10630 PACE Supplemental Questionnaire AttachmentIIPACESupplementalQuestions.pdf	Form
CMS-10630 PACE Audit Process and Data Request Protocol AttachmentIPACEAuditProcessDataRequest.pdf	Form and Instruction
CMS-10630 Onsite Audit AttachmentIVOnsiteObsPartList.pdf	Form
CMS-10630 Audit Survey AttachmentVAuditSurvey.pdf	Form and Instruction
CMS-10630 Service Delivery Request and Appeals Impact Analysis Tem Effectuation1P021P111P30.pdf	Form
CMS-10630 Clinical Appropriateness and Care Planning Impact Analys EmergencyCare1P07.pdf	Form
CMS-10630 Grievances Impact Analysis Template Grievances1P311P751P77.pdf	Form
CMS-10630 Clinical Appropriateness and Care Planning Impact Analys HomeCare1P02.pdf	Form
CMS-10630 Clinical Appropriateness and Care Planning Impact Analys MedErrors1P02.pdf	Form
CMS-10630 Personnel Impact Analysis Template Personnel.pdf	Form
CMS-10630 Clinical Appropriateness and Care Planning Impact Analys ProvisionofServices1P021P81.pdf	Form
CMS-10630 Clinical Appropriateness and Care Planning Impact Analys Restraints1P09.pdf	Form
CMS-10630 Root Cause Analysis Template RootCauseTemplate.pdf	Form
CMS-10630 Service Delivery Request Impact Analysis Template SDRIdentification1P76.pdf	Form
CMS-10630 Service Delivery Request Impact Analysis Template SDRs1P601P611P85.pdf	Form
CMS-10630 Clinical Appropriateness and Care Planning Impact Analys SrvcRestrict1P90.pdf	Form
CMS-10630 Clinical Appropriateness and Care Planning Impact Analys WoundCare1P02.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: Modified

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 and Care Planning Impact Analysis Template	Restraints1P09.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Clinical Appropriateness and Care Planning Impact Analysis Template	AlertIDT1P14.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Appeals Impact Analysis Template	AppealExt1P71.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Clinical Appropriateness and Care Planning Impact Analysis Template	MedErrors1P02.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Clinical Appropriateness and Care Planning Impact Analysis Template	ProvisionofServices1P021P81.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Root Cause Analysis Template	RootCauseTemplate.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Personnel Impact Analysis Template	Personnel.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Appeals Impact Analysis Template	Appeals1P651P661P681P73.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Clinical Appropriateness and Care Planning Impact Analysis Template	Assessments1P491P501P82.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10630	PACE Audit Process and Data Request Protocol	AttachmentIPACEAuditProcessDataRequest.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	PACE Supplemental Questionnaire	AttachmentIIPACESupplementalQuestions.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Summary of any pre-audit issues	AttachmentIIIPre-AuditIssueSummary.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Onsite Audit	AttachmentIVOnsiteObsPartList.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10630	Audit Survey	AttachmentVAuditSurvey.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Clinical Appropriateness and Care Planning Impact Analysis Template	EmergencyCare1P07.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Service Delivery Request and Appeals Impact Analysis Template	Effectuation1P021P111P30.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Grievances Impact Analysis Template	Grievances1P311P751P77.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Clinical Appropriateness and Care Planning Impact Analysis Template	HomeCare1P02.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Clinical Appropriateness and Care Planning Impact Analysis Template	SrvcRestrict1P90.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Service Delivery Request Impact Analysis Template	SDRIdentification1P76.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Service Delivery Request Impact Analysis Template	SDRs1P601P611P85.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Clinical Appropriateness and Care Planning Impact Analysis Template	WoundCare1P02.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: 131

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	35	-37	72
Annual IC Time Burden (Hours)	21,000	3,720	17,280
Annual IC Cost Burden (Dollars)	0	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.