Information Collection

Three-Year Network Adequacy Review for Medicare Advantage Organizations

IC 227912 under ICR 202208-0938-018 · OMB 0938-1346.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1346 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10636 Provider HSD Table Three-Year Network Adequacy Review for Medicare Advantage Organizations	Form
Form CMS-10636 Facility HSD Table Three-Year Network Adequacy Review for Medicare Advantage Organizations	Form
Form CMS-10636 Exception Request Template Three-Year Network Adequacy Review for Medicare Advantage Organizations	Form
Form CMS-10636 Partial County Justification Template Three-Year Network Adequacy Review for Medicare Advantage Organizations	Form and Instruction
MA_Network_Adequacy_Guidance_ updated 083022_CMS4192_F_CLEAN.pdf	Instruction
MA_Network_Adequacy_Guidance_ updated 083022_CMS4192_F_CLEAN.pdf	Instruction
HPMS Network Managment Module.JPG	Instruction
HPMS Network Managment Module.JPG	Instruction
CMS-10636 Provider HSD Table MA_Provider_Table_Template_REVISED (2022 version 2).pdf	Form
CMS-10636 Provider HSD Table MA_Provider_Table_Template_REVISED (2022 version 2).pdf	Form
CMS-10636 Facility HSD Table MA_Facility_Table_Template_REVISED (2022 version 2).pdf	Form
CMS-10636 Facility HSD Table MA_Facility_Table_Template_REVISED (2022 version 2).pdf	Form
CMS-10636 Exception Request Template MA_Exception_Template_11042021 (2022 version 2).pdf	Form
CMS-10636 Exception Request Template MA_Exception_Template_11042021 (2022 version 2).pdf	Form
CMS-10636 Partial County Justification Template Partial_County_Justification_Template_11042021 (2022 version 2).pdf	Form and Instruction
CMS-10636 Partial County Justification Template Partial_County_Justification_Template_11042021 (2022 version 2).pdf	Form and Instruction
MA_Network_Adequacy_Guidance_ 083022_CMS4192_F_TrackChanges.pdf Track Changes: Network Adequacy Guidance	IC Document
MA_Network_Adequacy_Guidance_ 083022_CMS4192_F_TrackChanges.pdf Track Changes: Network Adequacy Guidance	IC Document
CMS-10636 - CROSSWALK MA Network Adequacy Guidance.pdf Crosswalk: Network Adequacy Guidance	IC Document
CMS-10636 - CROSSWALK MA Network Adequacy Guidance.pdf Crosswalk: Network Adequacy Guidance	IC Document
MA_Provider_Table_Template_TC_090922.xlsx Track Changes: Provider HSD Table	IC Document
MA_Provider_Table_Template_TC_090922.xlsx Track Changes: Provider HSD Table	IC Document
Provider HSD Crosswalk OMB 0938-1346 090622.xlsx Crosswalk: Provider HSD Table	IC Document
Provider HSD Crosswalk OMB 0938-1346 090622.xlsx Crosswalk: Provider HSD Table	IC Document
MA_Facility_Table_Template_TC_090622.xlsx Track Changes: Facility HSD Table	IC Document
MA_Facility_Table_Template_TC_090622.xlsx Track Changes: Facility HSD Table	IC Document
Facility HSD Crosswalk OMB 0938-1346 090622.xlsx Crosswalk: Facility HSD Table	IC Document
Facility HSD Crosswalk OMB 0938-1346 090622.xlsx Crosswalk: Facility HSD Table	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Three-Year Network Adequacy Review for Medicare Advantage Organizations

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422 Section 112(a)(1)(i) 42 CFR 422 Section 114(a)(3)(ii)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction		Yes	No	Printable Only
Form	CMS-10636	Yes	Yes	Fillable Fileable
Form	CMS-10636	Yes	Yes	Fillable Fileable
Form	CMS-10636	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10636	Yes	Yes	Fillable Fileable
Instruction		Yes	No	Printable Only

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: 502

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	2,753	258	2,495
Annual IC Time Burden (Hours)	27,470	2,838	24,632
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Track Changes: Network Adequacy Guidance		09/01/2022
Crosswalk: Network Adequacy Guidance		09/01/2022
Track Changes: Provider HSD Table		09/06/2022
Crosswalk: Provider HSD Table		09/06/2022
Track Changes: Facility HSD Table		09/06/2022
Crosswalk: Facility HSD Table		09/06/2022

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

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