Information Collection

Three-Year Network Adequacy Review for Medicare Advantage Organizations

IC 227912 under ICR 202010-0938-003 · OMB 0938-1346.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.