Trial Year and Routine Audits

The PACE Organization (PO) Monitoring and Audit Process in Part 460 of 42 CFR (CMS-10630)

OMB: 0938-1327

IC ID: 225129

Documents and Forms

Document Name Document Type
Form CMS-10630 Trial Year and Routine Audits Form
CMS-10630 Clinical Appropriateness and Care Planning Impact Analys AlertIDT1P14.xlsx Form
CMS-10630 Clinical Appropriateness and Care Planning Impact Analys AlertIDT1P14.xlsx Form
CMS-10630 Appeals Impact Analysis Template Appeals1P651P661P681P73.xlsx Form
CMS-10630 Appeals Impact Analysis Template Appeals1P651P661P681P73.xlsx Form
CMS-10630 Clinical Appropriateness and Care Planning Impact Analys Assessments1P491P50.xlsx Form
CMS-10630 Clinical Appropriateness and Care Planning Impact Analys Assessments1P491P50.xlsx Form
CMS-10630 Summary of any pre-audit issues AttachmentIIIPreAuditIssueSummary.xlsx Form
CMS-10630 Summary of any pre-audit issues AttachmentIIIPreAuditIssueSummary.xlsx Form
CMS-10630 PACE Supplemental Questionnaire AttachmentIIPACESupplementalQuestions.xlsx Form
CMS-10630 PACE Supplemental Questionnaire AttachmentIIPACESupplementalQuestions.xlsx Form
CMS-10630 PACE Audit Process and Data Request Protocol AttachmentIPACEAuditProtocol.pdf Form and Instruction
CMS-10630 PACE Audit Process and Data Request Protocol AttachmentIPACEAuditProtocol.pdf Form and Instruction
CMS-10630 Corrective Action Plan (CAP) Process AttachmentVCorrectiveActionPlanProcess.pdf Form
CMS-10630 Corrective Action Plan (CAP) Process AttachmentVCorrectiveActionPlanProcess.pdf Form
CMS-10630 Audit Survey AttachmentIVAuditSurvey.pdf Form and Instruction
CMS-10630 Audit Survey AttachmentIVAuditSurvey.pdf Form and Instruction
CMS-10630 Service Delivery Request and Appeals Impact Analysis Tem Effectuation1P021P111P30.xlsx Form
CMS-10630 Service Delivery Request and Appeals Impact Analysis Tem Effectuation1P021P111P30.xlsx Form
CMS-10630 Clinical Appropriateness and Care Planning Impact Analys EmergencyCare1P07.xlsx Form
CMS-10630 Clinical Appropriateness and Care Planning Impact Analys EmergencyCare1P07.xlsx Form
CMS-10630 Grievances Impact Analysis Template Grievances1P311P751P77.xlsx Form
CMS-10630 Grievances Impact Analysis Template Grievances1P311P751P77.xlsx Form
CMS-10630 Clinical Appropriateness and Care Planning Impact Analys HomeCare1P02.xlsx Form
CMS-10630 Clinical Appropriateness and Care Planning Impact Analys HomeCare1P02.xlsx Form
CMS-10630 Clinical Appropriateness and Care Planning Impact Analys MedErrors1P02.xlsx Form
CMS-10630 Clinical Appropriateness and Care Planning Impact Analys MedErrors1P02.xlsx Form
CMS-10630 Personnel Impact Analysis Template Personnel.xlsx Form
CMS-10630 Personnel Impact Analysis Template Personnel.xlsx Form
CMS-10630 Clinical Appropriateness and Care Planning Impact Analys ProvisionofServices1P02.xlsx Form
CMS-10630 Clinical Appropriateness and Care Planning Impact Analys ProvisionofServices1P02.xlsx Form
CMS-10630 Clinical Appropriateness and Care Planning Impact Analys Restraints1P09.xlsx Form
CMS-10630 Clinical Appropriateness and Care Planning Impact Analys Restraints1P09.xlsx Form
CMS-10630 Root Cause Analysis Template RootCauseTemplate.xlsx Form
CMS-10630 Root Cause Analysis Template RootCauseTemplate.xlsx Form
CMS-10630 Service Delivery Request Impact Analysis Template SDRIdentification1P76.xlsx Form
CMS-10630 Service Delivery Request Impact Analysis Template SDRIdentification1P76.xlsx Form
CMS-10630 Service Delivery Request Impact Analysis Template SDRs1P601P611P85.xlsx Form
CMS-10630 Service Delivery Request Impact Analysis Template SDRs1P601P611P85.xlsx Form
CMS-10630 Clinical Appropriateness and Care Planning Impact Analys SrvcRestrict1P90.xlsx Form
CMS-10630 Clinical Appropriateness and Care Planning Impact Analys SrvcRestrict1P90.xlsx Form
CMS-10630 Clinical Appropriateness and Care Planning Impact Analys WoundCare1P02.xlsx Form
CMS-10630 Clinical Appropriateness and Care Planning Impact Analys WoundCare1P02.xlsx Form
CMS-10630 Coordination of Care CoordinationofCare1P95.xlsx Form
CMS-10630 Coordination of Care CoordinationofCare1P95.xlsx Form
CMS-10630 Required Services RequiredServices1P93.xlsx Form
CMS-10630 Required Services RequiredServices1P93.xlsx Form
CMS-10630 Special Recommendations SpecialistRecommendations1P94.xlsx Form
CMS-10630 Special Recommendations SpecialistRecommendations1P94.xlsx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Trial Year and Routine Audits	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 460.192 42 CFR 460.190

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10630	Clinical Appropriateness and Care Planning Impact Analysis Template	AlertIDT1P14.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10630	Appeals Impact Analysis Template	Appeals1P651P661P681P73.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10630	Clinical Appropriateness and Care Planning Impact Analysis Template	Assessments1P491P50.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10630	Summary of any pre-audit issues	AttachmentIIIPreAuditIssueSummary.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10630	PACE Supplemental Questionnaire	AttachmentIIPACESupplementalQuestions.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10630	PACE Audit Process and Data Request Protocol	AttachmentIPACEAuditProtocol.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Corrective Action Plan (CAP) Process	AttachmentVCorrectiveActionPlanProcess.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10630	Audit Survey	AttachmentIVAuditSurvey.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10630	Service Delivery Request and Appeals Impact Analysis Template	Effectuation1P021P111P30.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10630	Clinical Appropriateness and Care Planning Impact Analysis Template	EmergencyCare1P07.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10630	Grievances Impact Analysis Template	Grievances1P311P751P77.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10630	Clinical Appropriateness and Care Planning Impact Analysis Template	HomeCare1P02.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10630	Clinical Appropriateness and Care Planning Impact Analysis Template	MedErrors1P02.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10630	Personnel Impact Analysis Template	Personnel.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10630	Clinical Appropriateness and Care Planning Impact Analysis Template	ProvisionofServices1P02.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10630	Clinical Appropriateness and Care Planning Impact Analysis Template	Restraints1P09.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10630	Root Cause Analysis Template	RootCauseTemplate.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10630	Service Delivery Request Impact Analysis Template	SDRIdentification1P76.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10630	Service Delivery Request Impact Analysis Template	SDRs1P601P611P85.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10630	Clinical Appropriateness and Care Planning Impact Analysis Template	SrvcRestrict1P90.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10630	Clinical Appropriateness and Care Planning Impact Analysis Template	WoundCare1P02.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10630	Coordination of Care	CoordinationofCare1P95.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10630	Required Services	RequiredServices1P93.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10630	Special Recommendations	SpecialistRecommendations1P94.xlsx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 145	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 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	40	5	35
Annual IC Time Burden (Hours)	31,200	10,200	21,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.