Information Collection

Trial Year and Routine Audits

IC 225129 under ICR 202205-0938-008 · OMB 0938-1327.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1327 can be found here:

2025-07-16 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.