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⚠️ Notice: This information collection may be referencing outdated material.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

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:

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 %

	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

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.