Information Collection

Three-Year Network Adequacy Review for Medicare Advantage Organizations

IC 227912 under ICR 202305-0938-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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
MA_Network_Adequacy_Guidance_4201-F_CLEAN_03072023.docx	Instruction
MA_Network_Adequacy_Guidance_4201-F_CLEAN_03072023.docx	Instruction
HPMS Network Managment Module.JPG	Other-Screen Shot: HPMS Web Based Ap
HPMS Network Managment Module.JPG	Other-Screen Shot: HPMS Web Based Ap
LOI Upload Page NMM HPMS.jpg	Other-Screen Sot: LOI Upload Page
LOI Upload Page NMM HPMS.jpg	Other-Screen Sot: LOI Upload Page
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_Template_REVISED_03072023.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
CMS-10636 Partial County Justification Template Partial_County_Justification_Template_11042021 (2022 version 2).pdf	Form and Instruction
CMS-10636 LOI Group to NPI Matrix Template LOI Group to NPI matrix template.xlsx	Form
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_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
MA_Network_Adequacy_Guidance_4201-F_TC_03072023.docx Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance (Track Change)	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 114(a)(3)(ii) 42 CFR 422 Section 112(a)(1)(i)

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			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

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
	Approved	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
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

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