Information Collection

Program Audits

IC 242155 under ICR 202006-0938-004 · OMB 0938-1395.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1395 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10717 Pre Audit Issue Summary Program Audits	Form
Form CMS-10717 CPE Compliance Officer Questionnaire Program Audits	Form and Instruction
Form CMS-10717 Part D Formulary and Benefit Administration (FA) Supplemental Questionnaire Program Audits	Form and Instruction
Form CMS-10717 First Tier, Downstream, and Related Entities Operations Oversight Questionnaire Program Audits	Form and Instruction
Form CMS-10717 Independent Validation Audit Work Plan Program Audits	Form and Instruction
Form CMS-10717 Root Cause Analysis Program Audits	Form
Form CMS-10717 Special Needs Plans - Care Coordination Supplemental Questionnaire Program Audits	Form and Instruction
CPE_Protocol_508.pdf	Instruction
Compliance Program Effectiveness (CPE) Audit Protocol.pdf	Instruction
FA_Protocol_508.pdf	Instruction
Part D Formulary and Benefit Administration (FA) Audit Protocol.pdf	Instruction
CDAG_Protocol_508.pdf	Instruction
Part D Coverage Determinations, Appeals, and Grievances (CDAG) Audit Protocol.pdf	Instruction
ODAG_Protocol_508 .pdf	Instruction
Part C Organization Determinations, Appeals, and Grievances (ODAG) Audit Protocol.pdf	Instruction
SNPCC_Protocol_508.pdf	Instruction
Special Needs Plans Care Coordination (SNPCC) Audit Protocol.pdf	Instruction
Org_PowerPoint_508.pdf	Instruction
PowerPoint_Presentation_508.pdf	Instruction
ODAG_Protocol_508.pdf	Instruction
CMS-10717 Pre Audit Issue Summary PreAuditIssueSummary.pdf	Form
CMS-10717 Pre Audit Issue Summary Pre-Audit_Issue_Summary_508.pdf	Form
CMS-10717 CPE Compliance Officer Questionnaire CO_Questionnaire_508.pdf	Form and Instruction
CMS-10717 CPE Compliance Officer Questionnaire CO_Questionnaire_508.pdf	Form and Instruction
CMS-10717 Part D Formulary and Benefit Administration (FA) Supplem FAQuestionnaire_508.pdf	Form and Instruction
CMS-10717 Part D Formulary and Benefit Administration (FA) Supplem FA_Questionnaire_508.pdf	Form and Instruction
CMS-10717 First Tier, Downstream, and Related Entities Operations FTE_Oversight_Quest_508.pdf	Form and Instruction
CMS-10717 First Tier, Downstream, and Related Entities Operations FDR_Questionnaire_508.pdf	Form and Instruction
CMS-10717 Independent Validation Audit Work Plan Indep_Validation_508.pdf	Form and Instruction
CMS-10717 Independent Validation Audit Work Plan Independent_Validation_508.pdf	Form and Instruction
CMS-10717 Root Cause Analysis RootCauseTemplate_508.pdf	Form
CMS-10717 Root Cause Analysis Root_Cause_Analysis_508.pdf	Form
CMS-10717 Special Needs Plans - Care Coordination Supplemental Que SNPCC_Supp_ Quest_508.pdf	Form and Instruction
CMS-10717 Special Needs Plans - Care Coordination Supplemental Que SNPCC_Questionnaire_508.pdf	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Program Audits

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.504 42 CFR 423.505 42 CFR 423.514

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction		Yes	Yes	Printable Only
Instruction		Yes	Yes	Printable Only
Instruction		Yes	Yes	Printable Only
Instruction		Yes	Yes	Printable Only
Instruction		Yes	Yes	Printable Only
Form	CMS-10717	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10717	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10717	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10717	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10717	Yes	Yes	Fillable Printable
Instruction		Yes	Yes	Printable Only
Form	CMS-10717	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10717	Yes	Yes	Fillable Printable
Instruction		Yes	Yes	Fillable Printable

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: 25

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
Annual Number of Responses for this IC	25	25
Annual IC Time Burden (Hours)	17,525	17,525
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.

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