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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.