Information Collection

Three-Year Network Adequacy Review for Medicare Advantage Organizations

IC 227912 under ICR 202303-0938-009 · 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⚠️ Notice: This information collection may be referencing outdated material.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
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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.