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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
OMB.report
HHS/CMS
OMB 0938-1346
ICR 202406-0938-016
IC 227912
( )
Documents and Forms
Document Name
Document Type
MA_Network_Adequacy_Guidance_4201-F_CLEAN_508_03072023.pdf
Instruction
CMS-10636 Provider HSD Table
MA_Provider_Table_Template NEW 508_02072024.pdf
Form
CMS-10636 Facility HSD Table
MA_Facility_Table_Template NEW 508_02072024.pdf
Form
CMS-10636 Exception Request Template
MA_Exception_Template_REVISED_03072023.pdf
Form
CMS-10636 Partial County Justification Template
Partial_County_Justification_Template_11042021 (2022 version 2).pdf
Form and Instruction
HPMS Network Managment Module.JPG
Other-Screen Shot: HPMS Web Based Application
HPMS NMM LOI Upload Page NEW 508 03042024.pdf
Other-Screen Sot: LOI Upload Page
CMS-10636 LOI Group to NPI Matrix Template
LOI Group to NPI matrix template.xlsx
Form
Facility HSD Table Crosswalk 508 02072024.pdf
Facility HSD Table Crosswalk
IC Document
Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance Crosswalk 508 02072024.pdf
Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance (crosswalk)
IC Document
HPMS NMM Crosswalk 508 02072024.pdf
HPMS NMM Crosswalk
IC Document
Provider HSD Table Crosswalk 508 02072024.pdf
Provider HSD Table Crosswalk
IC Document
Information Collection (IC) Details
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