Information Collection

Essential Community Provider and Network Adequacy Data Requirements

IC 251109 under ICR 202201-0938-016 · OMB 0938-1415.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1415 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10803 Essential Community Provider and Network Adequacy Data Requirements	Form and Instruction
CMS-10803 Appendix A CMS-10803 - Appendix_A_Template.pdf	Form and Instruction
CMS-10803 Appendix A CMS-10803 - Appendix_A_Template.pdf	Form and Instruction
CMS-10803 - Appendix_B_Issuer_Module_Mockup.pdf Appendix B - User Module Mockup	IC Document
CMS-10803 - Appendix_B_Issuer_Module_Mockup.pdf Appendix B - User Module Mockup	IC Document

IC Title:

Essential Community Provider and Network Adequacy Data Requirements

Agency IC Tracking Number:

CMS-10803

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 156.230 45 CFR 156.235

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10803	Appendix A	CMS-10803 - Appendix_A_Template.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 485

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	485	485
Annual IC Time Burden (Hours)	5,380	5,380
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix B - User Module Mockup	CMS-10803 - Appendix_B_Issuer_Module_Mockup.pdf	01/11/2022

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.