Form CMS-10803 Appendix A

OMB control number: 0938-NEW
Expiration Date: XX/XX/20XX
ECP/NA template screenshots
ECP/NA Template - User Control Tab:

PRA DISCLOSURE:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0938-NEW, expiration
date is XX/XX/20XX. The time required to complete this information collection is estimated to take up to 20 hours per QHP
issuer per year and 4 hours per SADP issuer per year, including the time to review instructions, gather the information needed,
and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments,
medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the associated OMB control number listed
on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your
documents, please contact Nikolas Berkobien at [email protected].

ECP/NA Template – Select ECPs Tab:

ECP/NA Template – Facility ECPs Tab:

ECP/NA Template – Individual Providers (NA) Tab:

ECP/NA Template – Facility Providers (NA) Tab:

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ECP/NA Template – Taxonomy Codes Tab:

ECP/NA Template – County Names Tab:

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