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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			MA_Network_Adequacy_Guidance_ updated 083022_CMS4192_F_CLEAN.pdf	Yes	No	Printable Only
Form	CMS-10636	Provider HSD Table	MA_Provider_Table_Template_REVISED (2022 version 2).pdf	Yes	Yes	Fillable Fileable
Form	CMS-10636	Facility HSD Table	MA_Facility_Table_Template_REVISED (2022 version 2).pdf	Yes	Yes	Fillable Fileable
Form	CMS-10636	Exception Request Template	MA_Exception_Template_11042021 (2022 version 2).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10636	Partial County Justification Template	Partial_County_Justification_Template_11042021 (2022 version 2).pdf	Yes	Yes	Fillable Fileable
Instruction			HPMS Network Managment Module.JPG	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 %

	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

Title	Document	Date Uploaded
Track Changes: Network Adequacy Guidance	MA_Network_Adequacy_Guidance_ 083022_CMS4192_F_TrackChanges.pdf	09/01/2022
Crosswalk: Network Adequacy Guidance	CMS-10636 - CROSSWALK MA Network Adequacy Guidance.pdf	09/01/2022
Track Changes: Provider HSD Table	MA_Provider_Table_Template_TC_090922.xlsx	09/06/2022
Crosswalk: Provider HSD Table	Provider HSD Crosswalk OMB 0938-1346 090622.xlsx	09/06/2022
Track Changes: Facility HSD Table	MA_Facility_Table_Template_TC_090622.xlsx	09/06/2022
Crosswalk: Facility HSD Table	Facility HSD Crosswalk OMB 0938-1346 090622.xlsx	09/06/2022

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