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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
CPE_Protocol_508.pdf Instruction
FA_Protocol_508.pdf Instruction
CDAG_Protocol_508.pdf Instruction
ODAG_Protocol_508 .pdf Instruction
SNPCC_Protocol_508.pdf Instruction
Org_PowerPoint_508.pdf Instruction
CMS-10717 Pre Audit Issue Summary PreAuditIssueSummary.pdf Form
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 First Tier, Downstream, and Related Entities Operations FTE_Oversight_Quest_508.pdf Form and Instruction
CMS-10717 Independent Validation Audit Work Plan Indep_Validation_508.pdf Form and Instruction
CMS-10717 Root Cause Analysis RootCauseTemplate_508.pdf Form
CMS-10717 Special Needs Plans - Care Coordination Supplemental Que SNPCC_Supp_ Quest_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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CPE_Protocol_508.pdf	Yes	Yes	Printable Only
Instruction			FA_Protocol_508.pdf	Yes	Yes	Printable Only
Instruction			CDAG_Protocol_508.pdf	Yes	Yes	Printable Only
Instruction			ODAG_Protocol_508 .pdf	Yes	Yes	Printable Only
Instruction			SNPCC_Protocol_508.pdf	Yes	Yes	Printable Only
Form	CMS-10717	Pre Audit Issue Summary	PreAuditIssueSummary.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10717	CPE Compliance Officer Questionnaire	CO_Questionnaire_508.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10717	Part D Formulary and Benefit Administration (FA) Supplemental Questionnaire	FAQuestionnaire_508.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10717	First Tier, Downstream, and Related Entities Operations Oversight Questionnaire	FTE_Oversight_Quest_508.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10717	Independent Validation Audit Work Plan	Indep_Validation_508.pdf	Yes	Yes	Fillable Printable
Instruction			Org_PowerPoint_508.pdf	Yes	Yes	Printable Only
Form	CMS-10717	Root Cause Analysis	RootCauseTemplate_508.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10717	Special Needs Plans - Care Coordination Supplemental Questionnaire	SNPCC_Supp_ Quest_508.pdf	Yes	Yes	Fillable Printable

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 %

	Requested	Program Change Due to New Statute
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

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.