Three-Year Network Adequacy Review for Medicare Advantage Organizations

Triennial Network Adequacy Review for Medicare Advantage Organizations and 1876 Cost Plans (CMS-10636)

OMB: 0938-1346

IC ID: 227912

Documents and Forms
Document Name
Document Type
Instruction
Instruction
Other-Screen Shot: HPMS Web Based Ap
Other-Screen Shot: HPMS Web Based Ap
Other-Screen Sot: LOI Upload Page
Other-Screen Sot: LOI Upload Page
Form
Form
Form
Form
Form
Form
Form and Instruction
Form and Instruction
Form
Form
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Three-Year Network Adequacy Review for Medicare Advantage Organizations
 
No Modified
 
Mandatory
 
42 CFR 422 Section 112(a)(1)(i) 42 CFR 422 Section 114(a)(3)(ii)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction MA_Network_Adequacy_Guidance_4201-F_CLEAN_508_03072023.pdf Yes No Printable Only
Form CMS-10636 Provider HSD Table MA_Provider_Table_Template NEW 508_02072024.pdf Yes Yes Fillable Fileable
Form CMS-10636 Facility HSD Table MA_Facility_Table_Template NEW 508_02072024.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 HPMS NMM LOI Upload Page NEW 508 03042024.pdf Yes Yes Fillable Fileable
Form CMS-10636 LOI Group to NPI Matrix Template LOI Group to NPI matrix template.xlsx Yes Yes Fillable Fileable

Health Health Care Services

 

502 0
   
Private Sector Businesses or other for-profits
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,753 0 0 0 0 2,753
Annual IC Time Burden (Hours) 27,470 0 0 0 0 27,470
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Facility HSD Table Crosswalk Facility HSD Table Crosswalk 508 02072024.pdf 06/26/2024
Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance (crosswalk) Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance Crosswalk 508 02072024.pdf 06/26/2024
HPMS NMM Crosswalk HPMS NMM Crosswalk 508 02072024.pdf 06/26/2024
Provider HSD Table Crosswalk Provider HSD Table Crosswalk 508 02072024.pdf 06/26/2024
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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