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IDI Discussion Guide
Medicare Plan Performance Warning Information (CMS-10836)
OMB: 0938-1456
IC ID: 259113
OMB.report
HHS/CMS
OMB 0938-1456
ICR 202303-0938-005
IC 259113
( )
Documents and Forms
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
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
IDI Discussion Guide
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:
Document Type
Form No.
Form Name
Instrument File
URL
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
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:
288
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
288
0
0
288
0
0
Annual IC Time Burden (Hours)
432
0
0
432
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
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.