Information Collection

IDI Discussion Guide

IC 259113 under ICR 202303-0938-005 · OMB 0938-1456.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10836 IDI Discussion Guide	Form and Instruction
CMS-10836 Audits and Letters - Beneficiaries and Caregivers Plan Performance Warning - C - Guide 1 (Beneficiary) Audits and Letters_112022.pdf	Form and Instruction
CMS-10836 Audits and Letters - Intermediaries Plan Performance Warning - D - Guide 1 (Intermediaries) Audits and Letters_112022.pdf	Form and Instruction
CMS-10836 Enforcement and Compliance Information - Beneficiaries Plan Performance Warning - E - Guide 2 (Beneficiaries) Enforcement and Compliance Information_112022.pdf	Form and Instruction
CMS-10836 Enforcement and Compliance Information - Intermediaries Plan Performance Warning - F - Guide 2 (Intermediaries) Enforcement and Compliance Information_112022.pdf	Form and Instruction
CMS-10836 Poor Plan Performance - Beneficiaries Plan Performance Warning - G - Guide 3 (Beneficiaries) Poor Plan Performance_112022.pdf	Form and Instruction
CMS-10836 Poor Plan Performance - Intemediaries Plan Performance Warning - H - Guide 3 (Intermediaries) Poor Plan Performance_112022.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 422.152

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 and Instruction	CMS-10836	Audits and Letters - Beneficiaries and Caregivers	Plan Performance Warning - C - Guide 1 (Beneficiary) Audits and Letters_112022.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10836	Audits and Letters - Intermediaries	Plan Performance Warning - D - Guide 1 (Intermediaries) Audits and Letters_112022.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10836	Enforcement and Compliance Information - Beneficiaries	Plan Performance Warning - E - Guide 2 (Beneficiaries) Enforcement and Compliance Information_112022.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10836	Enforcement and Compliance Information - Intermediaries	Plan Performance Warning - F - Guide 2 (Intermediaries) Enforcement and Compliance Information_112022.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10836	Poor Plan Performance - Beneficiaries	Plan Performance Warning - G - Guide 3 (Beneficiaries) Poor Plan Performance_112022.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10836	Poor Plan Performance - Intemediaries	Plan Performance Warning - H - Guide 3 (Intermediaries) Poor Plan Performance_112022.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 288

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	288	288
Annual IC Time Burden (Hours)	432	432
Annual IC Cost Burden (Dollars)	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.