Information Collection

Medicare Part C and Part D Data Validation (42 CFR 422.516(g) and 423.514(g))

IC 194762 under ICR 202208-0938-008 · OMB 0938-1115.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1115 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CY 2023 DV Appendix B_Draft_20220708_508.pdf	Instruction
CY 2023 DV Appendix B_20221014_508.pdf	Instruction
CY 2023 DV_DV Procedure Manual_Draft_20220308_508.pdf	Instruction
CY 2023 DV_DV Procedure Manual_20221014.pdf	Instruction
CMS-10305 Appendix J_FDCF Appendix J_FDCF_Final_06022021_508.xlsx	Form and Instruction
CMS-10305 Organizational Assessment Instrument CY 2023 DV_Appendix E_Draft_20220309_508.pdf	Form and Instruction
CMS-10305 Organizational Assessment Instrument CY 2023 DV_Appendix E_20221014_508.pdf	Form and Instruction
CMS-10305 Grievances (Part C)_2022 CY 2023 DV Appendix J_C-Grievances_20221014_508.pdf	Form and Instruction
CMS-10305 Grievances (Part D) _2022 CY 2023 DV Appendix J_D-Grievances_20221014_508.pdf	Form and Instruction
CMS-10305 Coverage Determinations and Redeterminations (Part D) 20 CY 2023 DV Appendix J_CDR_20221014_508.pdf	Form and Instruction
CMS-10305 Improving Drug Utilization Review Controls (Part D) 2022 CY 2023 DV Appendix J_DUR_20221014_508.pdf	Form and Instruction
CMS-10305 Medication Therapy Management (MTM) Programs (Part D) 20 CY 2023 DV Appendix J_MTM_20221014_508.pdf	Form and Instruction
CMS-10305 Organization Determinations/Reconsiderations (Part C) 20 CY 2023 DV Appendix J_ODR_20221014_508.pdf	Form and Instruction
CMS-10305 Special Needs Plans (SNPs) Care Management 2022 CY 2023 DV Appendix J_SNP_20221014_508.pdf	Form and Instruction
CY2022 to CY2023 DV Appendix B Crosswalk of Changes_Draft_20220714.pdf Appendix B Crosswalk	IC Document
CY2022 to CY2023 DV Appendix B Crosswalk of Changes_Draft_20220714.pdf Appendix B Crosswalk	IC Document
CY2022 to CY2023 DV Appendix J Crosswalk of Changes_Draft_20220714.pdf Appendix J Crosswalk	IC Document
CY2022 to CY2023 DV Appendix J Crosswalk of Changes_Draft_20220714.pdf Appendix J Crosswalk	IC Document
Crosswalk of Changes from CY2022 to CY2023_App E_Draft_20220310_508.pdf Appendix E: Crosswalk	IC Document
Crosswalk of Changes from CY2022 to CY2023_App E_Draft_20220310_508.pdf Appendix E: Crosswalk	IC Document
CY2022 to CY2023 Appendix B DV Crosswalk_Post 30-Day PRA_20221014_508.pdf Appendix B DV Crosswalk_Post 30-Day	IC Document
CY2022 to CY2023 Appendix J DV Crosswalk_Post 30-Day PRA_20221014_508.pdf Appendix J DV Crosswalk_Post 30-Day	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Medicare Part C and Part D Data Validation (42 CFR 422.516(g) and 423.514(g))

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.516(a)(3),(a)(4),(a)(6) 42 CFR 423.514 (a)(3) (a) (4) (a) (6) 42 CFR 423.514 (a)(1) (a) (2) 42 CFR 422.516_(a)(1),(a)(2)

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
Instruction			CY 2023 DV Appendix B_20221014_508.pdf	Yes	No	Printable Only
Instruction			CY 2023 DV_DV Procedure Manual_20221014.pdf	Yes	No	Fillable Printable
Form and Instruction	CMS-10305	Organizational Assessment Instrument	CY 2023 DV_Appendix E_20221014_508.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10305	Grievances (Part C)_2022	CY 2023 DV Appendix J_C-Grievances_20221014_508.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10305	Grievances (Part D) _2022	CY 2023 DV Appendix J_D-Grievances_20221014_508.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10305	Coverage Determinations and Redeterminations (Part D) 2022	CY 2023 DV Appendix J_CDR_20221014_508.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10305	Improving Drug Utilization Review Controls (Part D) 2022	CY 2023 DV Appendix J_DUR_20221014_508.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10305	Medication Therapy Management (MTM) Programs (Part D) 2022	CY 2023 DV Appendix J_MTM_20221014_508.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10305	Organization Determinations/Reconsiderations (Part C) 2022	CY 2023 DV Appendix J_ODR_20221014_508.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10305	Special Needs Plans (SNPs) Care Management 2022	CY 2023 DV Appendix J_SNP_20221014_508.pdf	Yes	Yes	Fillable Printable

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: 793

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	793	32	761
Annual IC Time Burden (Hours)	21,535	589	20,946
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix B Crosswalk	CY2022 to CY2023 DV Appendix B Crosswalk of Changes_Draft_20220714.pdf	08/04/2022
Appendix J Crosswalk	CY2022 to CY2023 DV Appendix J Crosswalk of Changes_Draft_20220714.pdf	08/04/2022
Appendix E: Crosswalk	Crosswalk of Changes from CY2022 to CY2023_App E_Draft_20220310_508.pdf	08/04/2022
Appendix B DV Crosswalk_Post 30-Day	CY2022 to CY2023 Appendix B DV Crosswalk_Post 30-Day PRA_20221014_508.pdf	10/25/2022
Appendix J DV Crosswalk_Post 30-Day	CY2022 to CY2023 Appendix J DV Crosswalk_Post 30-Day PRA_20221014_508.pdf	10/25/2022

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