Information Collection

Essential Community Provider and Network Adequacy Data Requirements

IC 251109 under ICR 202403-0938-012 · OMB 0938-1415.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1415 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10803 Essential Community Provider and Network Adequacy Data Requirements	Form and Instruction
CMS-10803_Appendix_B_ECP-NA_Issuer_Module_Mockup_508.pdf	Other-Screenshots
CMS-10803_Appendix_B_ECP-NA_Issuer_Module_Mockup_508.pdf	Other-Screenshots
CMS-10803 Appendix A CMS-10803_Appendix_A_ECP-NA_Template_508.pdf	Form and Instruction
CMS-10803 Appendix A CMS-10803_Appendix_A_ECP-NA_Template_508.pdf	Form and Instruction
CMS-10803 - Appendix_B_Issuer_Module_Mockup.pdf Appendix B - User Module Mockup	IC Document
CMS-10803 - Appendix_B_Issuer_Module_Mockup.pdf Appendix B - User Module Mockup	IC Document

IC Title:

Essential Community Provider and Network Adequacy Data Requirements

Agency IC Tracking Number:

CMS-10803

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 156.235 45 CFR 156.230

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10803	Appendix A	CMS-10803_Appendix_A_ECP-NA_Template_508.pdf		Yes	Yes	Paper Only
Other-Screenshots			CMS-10803_Appendix_B_ECP-NA_Issuer_Module_Mockup_508.pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 365

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 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	365	0	-120	485
Annual IC Time Burden (Hours)	4,196	0	-1,184	5,380
Annual IC Cost Burden (Dollars)	316,583	316,583	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix B - User Module Mockup	CMS-10803 - Appendix_B_Issuer_Module_Mockup.pdf	01/11/2022

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