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⚠️ Notice: This information collection may be referencing outdated material.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

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.	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 %

table that charts list of burden
	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

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.