Information Collection

DE Entity Operational Readiness Review (ORR)

IC 263264 under ICR 202311-0938-002 · OMB 0938-1463.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1463 can be found here:

2024-04-22 - New collection (Request for a new OMB Control Number)

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10877 DE Entity Operational Readiness Review (ORR)	Form and Instruction
CMS-10877 - Appendix_G_API-Functional-Integration-Toolkit.pdf	Instruction
CMS-10877 - Appendix_G_API-Functional-Integration-Toolkit.pdf	Instruction
CMS-10877 Documentation and Audit Package CMS-10877 - Appendix_E_DEE-Documentation-Package.pdf	Form and Instruction
CMS-10877 Documentation and Audit Package CMS-10877 - Appendix_E_DEE-Documentation-Package.pdf	Form and Instruction
CMS-10877 Privacy Questiionaire CMS-10877 - Appendix_F_EDE-Privacy-Questionnaire.pdf	Form and Instruction
CMS-10877 Privacy Questiionaire CMS-10877 - Appendix_F_EDE-Privacy-Questionnaire.pdf	Form and Instruction
CMS-10877 Application User Interface Toolkit CMS-10877 - Appendix_H_Application-UI-Toolkit.pdf	Form and Instruction
CMS-10877 Application User Interface Toolkit CMS-10877 - Appendix_H_Application-UI-Toolkit.pdf	Form and Instruction
CMS-10877 Communications Toolkit CMS-10877 - Appendix_J_EDE-Business-Audit-Instructions-Report-Template.pdf	Form and Instruction
CMS-10877 Communications Toolkit CMS-10877 - Appendix_J_EDE-Business-Audit-Instructions-Report-Template.pdf	Form and Instruction
CMS-10877 Eligibility Results Toolkit CMS-10877 - Appendix_K_EDE-Eligibility-Results-Toolkit-Phase1.pdf	Form and Instruction
CMS-10877 Eligibility Results Toolkit CMS-10877 - Appendix_K_EDE-Eligibility-Results-Toolkit-Phase1.pdf	Form and Instruction
CMS-10877 Eligibility Results Toolkit - Phase 2 CMS-10877 - Appendix_L_EDE-Eligibility-Results-Toolkit-Phase2.pdf	Form and Instruction
CMS-10877 Eligibility Results Toolkit - Phase 2 CMS-10877 - Appendix_L_EDE-Eligibility-Results-Toolkit-Phase2.pdf	Form and Instruction
CMS-10877 Eligibility Results Toolkit - Phase 3 CMS-10877 - Appendix_M_EDE-Eligibility-Results-Toolkit-Phase3.pdf	Form and Instruction
CMS-10877 Eligibility Results Toolkit - Phase 3 CMS-10877 - Appendix_M_EDE-Eligibility-Results-Toolkit-Phase3.pdf	Form and Instruction
CMS-10877 Change Notification Form CMS-10877 - Appendix_N_EDE-Entity-Initiated-Change-Notification-Form_v2_508.pdf	Form and Instruction
CMS-10877 Change Notification Form CMS-10877 - Appendix_N_EDE-Entity-Initiated-Change-Notification-Form_v2_508.pdf	Form and Instruction
CMS-10877 Business Agreement BY 2024 CMS-10877 - Appendix_O_EDE_Business_Agreement_PY_2024_Final_508.pdf	Form and Instruction
CMS-10877 Business Agreement BY 2024 CMS-10877 - Appendix_O_EDE_Business_Agreement_PY_2024_Final_508.pdf	Form and Instruction
CMS-10877 INTERCONNECTION SECURITY AGREEMENT CMS-10877 - Appendix_Q_CMS-EDE-ISA-Template.pdf	Form
CMS-10877 INTERCONNECTION SECURITY AGREEMENT CMS-10877 - Appendix_Q_CMS-EDE-ISA-Template.pdf	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

DE Entity Operational Readiness Review (ORR)

Agency IC Tracking Number:

CCIIO - 10877

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.221

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
Form and Instruction	CMS-10877	Documentation and Audit Package	CMS-10877 - Appendix_E_DEE-Documentation-Package.pdf	Yes	No	Paper Only
Form and Instruction	CMS-10877	Privacy Questiionaire	CMS-10877 - Appendix_F_EDE-Privacy-Questionnaire.pdf	Yes	Yes	Fillable Fileable
Instruction			CMS-10877 - Appendix_G_API-Functional-Integration-Toolkit.pdf	Yes	No	Paper Only
Form and Instruction	CMS-10877	Application User Interface Toolkit	CMS-10877 - Appendix_H_Application-UI-Toolkit.pdf	Yes	No	Fillable Printable
Form and Instruction	CMS-10877	Communications Toolkit	CMS-10877 - Appendix_J_EDE-Business-Audit-Instructions-Report-Template.pdf	Yes	Yes	Paper Only
Form and Instruction	CMS-10877	Eligibility Results Toolkit	CMS-10877 - Appendix_K_EDE-Eligibility-Results-Toolkit-Phase1.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10877	Eligibility Results Toolkit - Phase 2	CMS-10877 - Appendix_L_EDE-Eligibility-Results-Toolkit-Phase2.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10877	Eligibility Results Toolkit - Phase 3	CMS-10877 - Appendix_M_EDE-Eligibility-Results-Toolkit-Phase3.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10877	Change Notification Form	CMS-10877 - Appendix_N_EDE-Entity-Initiated-Change-Notification-Form_v2_508.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10877	Business Agreement BY 2024	CMS-10877 - Appendix_O_EDE_Business_Agreement_PY_2024_Final_508.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10877	INTERCONNECTION SECURITY AGREEMENT	CMS-10877 - Appendix_Q_CMS-EDE-ISA-Template.pdf	Yes	No	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: 95

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: 0 %

table that charts list of burden
	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	95	95
Annual IC Time Burden (Hours)	2,689	2,689
Annual IC Cost Burden (Dollars)	200,372	200,372

Documents for IC

table that charts IC Documents
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.