Crosswalk: Facility HSD Table

Facility HSD Crosswalk OMB 0938-1346 090622.xlsx

Triennial Network Adequacy Review for Medicare Advantage Organizations and 1876 Cost Plans (CMS-10636)

Crosswalk: Facility HSD Table

OMB: 0938-1346

Document [xlsx]
Download: xlsx | pdf
# Form Change Current Location Reason
1 Facility HSD Table Addition of the column "Letter of Intent Y/N" to the Facility HSD Table Template, Column M New- Column M Facility HSD Table Template CMS-4192-F includes procedural changes to network reviews based on an MAO's status (applicant versus triennial), initial applicants and service area expansion applicants may use a letter of intent for purposes of network adequacy during the application process. The column is included on the facility HSD table for both applicant and triennial network submissions, however the completion of the column is optional and will not prohibit the organization from uploading in the Network Management Module if left blank.
File Typeapplication/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified0000-00-00
File Created0000-00-00

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