Three-Year Network Adequacy Review for Medicare Advantage Organizations

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

OMB: 0938-1346

IC ID: 227912

Information Collection (IC) Details

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Three-Year Network Adequacy Review for Medicare Advantage Organizations
 
No Modified
 
Mandatory
 
42 CFR 422 Section 112(a)(1)(i) 42 CFR 422 Section 114(a)(3)(ii)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction MA_Network_Adequacy_Guidance_ updated 012022_CMS4192_P.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_11.18.2020.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

Health Health Care Services

 

140 0
   
Private Sector Businesses or other for-profits
 
   100 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,495 0 0 0 0 2,495
Annual IC Time Burden (Hours) 24,632 0 0 0 0 24,632
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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