Information Collection

Program Audits

IC 242155 under ICR 202310-0938-002 · OMB 0938-1395.

Documents and Forms

Document Name Document Type
CPEProtocol.pdf Instruction
CPEProtocol.pdf Instruction
FAProtocol.pdf Instruction
FAProtocol.pdf Instruction
CDAGProtocol.pdf Instruction
CDAGProtocol.pdf Instruction
ODAGProtocol.pdf Instruction
ODAGProtocol.pdf Instruction
SNPCCProtocol.pdf Instruction
SNPCCProtocol.pdf Instruction
PowerPointPresentation.pdf Instruction
PowerPointPresentation.pdf Instruction
CMS-10717 Pre Audit Issue Summary PreAuditIssueSummary.pdf Form
CMS-10717 Pre Audit Issue Summary PreAuditIssueSummary.pdf Form
CMS-10717 CPE Compliance Officer Questionnaire Compliance Officer COQuestionnaire.pdf Form and Instruction
CMS-10717 CPE Compliance Officer Questionnaire Compliance Officer COQuestionnaire.pdf Form and Instruction
CMS-10717 Part D Formulary and Benefit Administration (FA) Supplem FASupplementalQuestionnaire.pdf Form and Instruction
CMS-10717 Part D Formulary and Benefit Administration (FA) Supplem FASupplementalQuestionnaire.pdf Form and Instruction
CMS-10717 First Tier, Downstream, and Related Entities Operations FDRQuestionnaire.pdf Form and Instruction
CMS-10717 First Tier, Downstream, and Related Entities Operations FDRQuestionnaire.pdf Form and Instruction
CMS-10717 Independent Validation Audit Work Plan IndependentValidation.pdf Form and Instruction
CMS-10717 Independent Validation Audit Work Plan IndependentValidation.pdf Form and Instruction
CMS-10717 Root Cause Analysis RootCauseAnalysis.pdf Form
CMS-10717 Root Cause Analysis RootCauseAnalysis.pdf Form
CMS-10717 Special Needs Plans - Care Coordination Supplemental Que SNPCCQuestionnaire.pdf Form and Instruction
CMS-10717 Special Needs Plans - Care Coordination Supplemental Que SNPCCQuestionnaire.pdf Form and Instruction
CMS-10717 Attendance Log for Meetings/Webinars/Conferences AttendanceLogTemplate.pdf Form and Instruction
CMS-10717 Attendance Log for Meetings/Webinars/Conferences AttendanceLogTemplate.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Program Audits	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.514 42 CFR 422.504 42 CFR 423.505

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CPEProtocol.pdf	Yes	Yes	Printable Only
Instruction			FAProtocol.pdf	Yes	Yes	Printable Only
Instruction			CDAGProtocol.pdf	Yes	Yes	Printable Only
Instruction			ODAGProtocol.pdf	Yes	Yes	Printable Only
Instruction			SNPCCProtocol.pdf	Yes	Yes	Printable Only
Form	CMS-10717	Pre Audit Issue Summary	PreAuditIssueSummary.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10717	CPE Compliance Officer Questionnaire Compliance Officer Questionnaire (CO-Q)	COQuestionnaire.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10717	Part D Formulary and Benefit Administration (FA) Supplemental Questionnaire	FASupplementalQuestionnaire.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10717	First Tier, Downstream, and Related Entities Operations Oversight Questionnaire	FDRQuestionnaire.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10717	Independent Validation Audit Work Plan	IndependentValidation.pdf	Yes	Yes	Fillable Printable
Instruction			PowerPointPresentation.pdf	Yes	Yes	Printable Only
Form	CMS-10717	Root Cause Analysis	RootCauseAnalysis.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10717	Special Needs Plans - Care Coordination Supplemental Questionnaire	SNPCCQuestionnaire.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10717	Attendance Log for Meetings/Webinars/Conferences	AttendanceLogTemplate.pdf	Yes	Yes	Fillable Printable

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: 25	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	25	25
Annual IC Time Burden (Hours)	17,525	17,525
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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