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
Instruction
Instruction
Other-Screen Shot: HPMS Web Based Ap
Other-Screen Shot: HPMS Web Based Ap
Other-Screen Sot: LOI Upload Page
Other-Screen Sot: LOI Upload Page
Form
Form
Form
Form
Form
Form
Form and Instruction
Form and Instruction
Form
Form
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Three-Year Network Adequacy Review for Medicare Advantage Organizations
 
No Modified
 
Mandatory
 
42 CFR 422 Section 114(a)(3)(ii) 42 CFR 422 Section 112(a)(1)(i)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction MA_Network_Adequacy_Guidance_4201-F_CLEAN_03072023.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_Template_REVISED_03072023.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
Other-Screen Shot: HPMS Web Based Application HPMS Network Managment Module.JPG Yes Yes Fillable Fileable
Other-Screen Sot: LOI Upload Page LOI Upload Page NMM HPMS.jpg Yes Yes Fillable Fileable
Form CMS-10636 LOI Group to NPI Matrix Template LOI Group to NPI matrix template.xlsx Yes Yes Fillable Fileable

Health Health Care Services

 

502 0
   
Private Sector Businesses or other for-profits
 
   100 %

  Approved 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 2,753 0 0 0 0 2,753
Annual IC Time Burden (Hours) 27,470 0 0 0 0 27,470
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Exception Request Template (Track Change) MA_Exception_Template_TC_03072023.pdf 09/22/2023
Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance (Track Change) MA_Network_Adequacy_Guidance_4201-F_TC_03072023.docx 09/22/2023
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