Three-Year Network Adequacy Review for Medicare Advantage Organizations

Triennial Network Adequacy Review for Medicare Advantage Organizations and 1876 Cost Plans (CMS-10636)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1346 can be found here:

Documents and Forms

Document Name Document Type
MA_Network_Adequacy_Guidance_06_17_20.pdf Instruction
HPMS Network Managment Module.JPG Instruction
CMS-10636 Provider Table MA_Provider_Table_Template_06_14_19.xlsx Form
CMS-10636 Facility Table MA_Facility_Table_Template_06_14_19.xlsx Form
CMS-10636 Exception Template MA_Exception_Template_2020.pdf Form
CMS-10636 Justification Template Partial_County_Justification_Template_2020.pdf Form

Information Collection (IC) Details

IC Title:	Three-Year Network Adequacy Review for Medicare Advantage Organizations	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422 Section 114(a)(3)(ii) 42 CFR 422 Section 112(a)(1)(i)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			MA_Network_Adequacy_Guidance_06_17_20.pdf	Yes	No	Printable Only
Form	CMS-10636	Provider Table	MA_Provider_Table_Template_06_14_19.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10636	Facility Table	MA_Facility_Table_Template_06_14_19.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10636	Exception Template	MA_Exception_Template_2020.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10636	Justification Template	Partial_County_Justification_Template_2020.pdf	Yes	Yes	Fillable Fileable
Instruction			HPMS Network Managment Module.JPG	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 140	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,432	-220	1,652
Annual IC Time Burden (Hours)	13,964	-1,728	15,692
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.