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

Documents and Forms

Document Name Document Type
MA_Network_Adequacy_Guidance_4201-F_CLEAN_03072023.docx Instruction
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 Exception Request Template MA_Exception_Template_REVISED_03072023.pdf Form
CMS-10636 Partial County Justification Template Partial_County_Justification_Template_11042021 (2022 version 2).pdf Form and Instruction
HPMS Network Managment Module.JPG Other-Screen Shot: HPMS Web Based Application
LOI Upload Page NMM HPMS.jpg Other-Screen Sot: LOI Upload Page
CMS-10636 LOI Group to NPI Matrix Template LOI Group to NPI matrix template.xlsx Form
MA_Exception_Template_TC_03072023.pdf Exception Request Template (Track Change) IC Document
MA_Network_Adequacy_Guidance_4201-F_TC_03072023.docx Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance (Track Change) IC Document