Information Collection

Medicare Parts C and D Program Audit Protocols and Data Requests

IC 43683 under ICR 201912-0938-020 · OMB 0938-1000.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form CMS-10191
Medicare Parts C and D Program Audit Protocols and Data Requests
Form and Instruction
CMS-10191 CPE Program Area Audit Process and Data Request
Attachment I CPEAuditProcessDataRequest.pdf
Form and Instruction
CMS-10191 CPE Compliance Officer Questionnaire
Attachment IA CPECompliance OfficerQuestionnaire.pdf
Form and Instruction
CMS-10191 CPE Audit Organizational Structure and Governance PPT Te
Attachment IB CPEOrganizationalStructureGovernancePPT.pdf
Form and Instruction
CMS-10191 Accountability for Oversight of First-Tier, Downstream a
Attachment IC CPEFDROversightQuestionnaireFDRQ.pdf
Form and Instruction
CMS-10191 SIU/FWA Prevention and Detection Questionnaire
Attachment ID CPESIUFWAQuestionnaireFWAQ.pdf
Form and Instruction
CMS-10191 FA Audit Process and Data Request
Attachment II FAAuditProcessDataRequest.pdf
Form and Instruction
CMS-10191 CDAG Audit Process and Data Request
Attachment_III_CDAG_AuditProcess_DataRequest.pdf
Form and Instruction
CMS-10191 ODAD Audit Process and Data Request
Attachment IV ODAGAuditProcessDataRequest.pdf
Form and Instruction
CMS-10191 SNP-MOC Audit Process and Data Request
Attachment V SNPMOCAuditProcessDataRequest.pdf
Form and Instruction
CMS-10191 SNP-MOC Questionnaire
Attachment_V-A_SNP-MOC_Questionnaire.pdf
Form and Instruction
CMS-10191 CDAG CDM Impact Analysis
CDAGCDMImpact.pdf
Form
CMS-10191 CDAG GRV Impact Analysis
CDAGGRVImpact.pdf
Form
CMS-10191 FA Impact Analysis
FAImpactAnalysis.pdf
Form
CMS-10191 ODAG DIS Impact
ODAGDISImpact.pdf
Form
CMS-10191 ODAG GRV Impact
ODAGGRVImpact.pdf
Form
CMS-10191 Pre Audit Issue Summary
PreAuditIssueSummary.pdf
Form
CMS-10191 SNP MOC ICP ICT Impact
SNPMOCICPICTImpact.pdf
Form
CMS-10191 SNP MOC Impact
SNPMOCImpact.pdf
Form
CMS-10191 SNP MOC Training Impact
SNPMOCTrainingImpact.pdf
Form
CMS-10191 ODAG CDM Impact
ODAGCDMImpact.pdf
Form
CMS-10191 ODAG PMNT Impact
ODAGPMNTImpact.pdf
Form
10191PRACrosswalk60Dto30D.pdf
60 Day Crosswalk
IC Document
10191 Crosswalk From 30 Day Comments.pdf
30 Day Crosswalk
IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

Information Collection Instruments:
table that charts list of instruments
Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10191 CPE Program Area Audit Process and Data Request Attachment I CPEAuditProcessDataRequest.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10191 CPE Compliance Officer Questionnaire Attachment IA CPECompliance OfficerQuestionnaire.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10191 CPE Audit Organizational Structure and Governance PPT Template Attachment IB CPEOrganizationalStructureGovernancePPT.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10191 Accountability for Oversight of First-Tier, Downstream and Related Entities Questionnaire Attachment IC CPEFDROversightQuestionnaireFDRQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10191 SIU/FWA Prevention and Detection Questionnaire Attachment ID CPESIUFWAQuestionnaireFWAQ.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10191 FA Audit Process and Data Request Attachment II FAAuditProcessDataRequest.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10191 ODAD Audit Process and Data Request Attachment IV ODAGAuditProcessDataRequest.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10191 SNP-MOC Audit Process and Data Request Attachment V SNPMOCAuditProcessDataRequest.pdf Yes Yes Fillable Fileable
Form CMS-10191 CDAG CDM Impact Analysis CDAGCDMImpact.pdf Yes Yes Fillable Fileable
Form CMS-10191 CDAG GRV Impact Analysis CDAGGRVImpact.pdf Yes Yes Fillable Fileable
Form CMS-10191 Pre Audit Issue Summary PreAuditIssueSummary.pdf Yes Yes Fillable Fileable
Form CMS-10191 FA Impact Analysis FAImpactAnalysis.pdf Yes Yes Fillable Fileable
Form CMS-10191 ODAG DIS Impact ODAGDISImpact.pdf Yes Yes Fillable Fileable
Form CMS-10191 ODAG GRV Impact ODAGGRVImpact.pdf Yes Yes Fillable Fileable
Form CMS-10191 SNP MOC ICP ICT Impact SNPMOCICPICTImpact.pdf Yes Yes Fillable Fileable
Form CMS-10191 SNP MOC Impact SNPMOCImpact.pdf Yes Yes Fillable Fileable
Form CMS-10191 SNP MOC Training Impact SNPMOCTrainingImpact.pdf Yes Yes Fillable Fileable
Form CMS-10191 ODAG CDM Impact ODAGCDMImpact.pdf Yes Yes Fillable Fileable
Form CMS-10191 ODAG PMNT Impact ODAGPMNTImpact.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10191 CDAG Audit Process and Data Request Attachment_III_CDAG_AuditProcess_DataRequest.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10191 SNP-MOC Questionnaire Attachment_V-A_SNP-MOC_Questionnaire.pdf Yes Yes Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 207 0 0 -34 0 241
Annual IC Time Burden (Hours) 39,456 0 0 -12,805 0 52,261
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
60 Day Crosswalk 10191PRACrosswalk60Dto30D.pdf 12/27/2019
30 Day Crosswalk 10191 Crosswalk From 30 Day Comments.pdf 02/10/2020
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.