Document Name Document Type
Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance CMS=4201-P version 1) Clean.docx Instruction
Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance CMS=4201-P version 1) Clean.docx Instruction
HPMS Web Based Application - Network Management Module (NMM).JPG Instruction
HPMS Web Based Application - Network Management Module (NMM).JPG Instruction
CMS-10636 Provider HSD Table MA_Provider_Table_Template_(2022 version 2).pdf Form
CMS-10636 Provider HSD Table MA_Provider_Table_Template_(2022 version 2).pdf Form
CMS-10636 Facility HSD Table MA_Facility_Table_Template_(2022 version 2).pdf Form
CMS-10636 Facility HSD Table MA_Facility_Table_Template_(2022 version 2).pdf Form
CMS-10636 Exception Request Template MA_Exception_Request_Template_(CMS-4201-P version 1).pdf Form
CMS-10636 Exception Request Template MA_Exception_Request_Template_(CMS-4201-P version 1).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
Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance CMS=4201-P version 1) Track Changes.docx Track Change: Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance (CMS-4201-P version 1) IC Document
Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance CMS=4201-P version 1) Track Changes.docx Track Change: Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance (CMS-4201-P version 1) IC Document
CMS-4201-P Crosswalk 10262022.xlsx Crosswalk IC Document
CMS-4201-P Crosswalk 10262022.xlsx Crosswalk 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			Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance CMS=4201-P version 1) Clean.docx	Yes	No	Printable Only
Form	CMS-10636	Provider HSD Table	MA_Provider_Table_Template_(2022 version 2).pdf	Yes	Yes	Fillable Fileable
Form	CMS-10636	Facility HSD Table	MA_Facility_Table_Template_(2022 version 2).pdf	Yes	Yes	Fillable Fileable
Form	CMS-10636	Exception Request Template	MA_Exception_Request_Template_(CMS-4201-P version 1).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 Web Based Application - Network Management Module (NMM).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 %

	Requested	Previously Approved
Annual Number of Responses for this IC	2,753	2,753
Annual IC Time Burden (Hours)	27,470	27,470
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Track Change: Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance (CMS-4201-P version 1)	Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance CMS=4201-P version 1) Track Changes.docx	03/15/2023
Crosswalk	CMS-4201-P Crosswalk 10262022.xlsx	03/15/2023

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

Three-Year Network Adequacy Review for Medicare Advantage Organizations

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

OMB: 0938-1346

IC ID: 227912

View Information Collection (IC)