Form CMS-10877 Documentation and Audit Package

Appendix E: DEE Documentation Package

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Expiration Date: XX/XX/20XX

PRODUCT_TYPE

PRA DISCLOSURE: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is
0938-NEW, expiration date is XX/XX/20XX. The time required to complete this information collection is estimated to take
up to 56,290 hours annually for all direct enrollment entities. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send
applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports
Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under
the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions
or concerns regarding where to submit your documents, please contact Brittany Cain at [email protected].

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Enroll_Outside_OE

Consumer_Pathway_URL

Website_URL

Corporate_Relationship

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Entity_Type Entity_ID ENTITY_NAME NAME_FOR_PUBLIC_LIST

PARTNER_ID

ADDRESS

ANNUAL_ID DBA_NAME

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Vendor

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STATE

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STATE

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STATE

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STATE

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STATE

RELATIONSHIP

ASSOCIATE_AGENT_ENTITY_NAME

NPN

NPN_TYPE LICENSE_NUMBER

EXPIRATION_DATE

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Arrangement_ID

EDE_Type
1
2
3

EDE_Pathway_Provider

Application_EndPhase

Pathway_Type

CMS_Issued_Partner_IDs

DE_EDE_Pthwy_HIOS_ID

Consumer_Shopping_URL

Additional_Arrangement

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DE_Platform_Type

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Entity_Name

Entity_Type

HIOS_IDs Partner_IDs

Pathway_Type

DE_Enrollments_Outside_OEP

Classic_DE_URL

EDE_URL

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Expiration Date: XX/XX/20XX