Information Collection

Three-Year Network Adequacy Review for Medicare Advantage Organizations

IC 227912 under ICR 202406-0938-016 · OMB 0938-1346.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1346 can be found here:

2024-12-18 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
MA_Network_Adequacy_Guidance_4201-F_CLEAN_508_03072023.pdf	Instruction
MA_Network_Adequacy_Guidance_4201-F_CLEAN_508_03072023.pdf	Instruction
HPMS Network Managment Module.JPG	Other-Screen Shot: HPMS Web Based Ap
HPMS Network Managment Module.JPG	Other-Screen Shot: HPMS Web Based Ap
HPMS NMM LOI Upload Page NEW 508 03042024.pdf	Other-Screen Sot: LOI Upload Page
HPMS NMM LOI Upload Page NEW 508 03042024.pdf	Other-Screen Sot: LOI Upload Page
CMS-10636 Provider HSD Table MA_Provider_Table_Template NEW 508_02072024.pdf	Form
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 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 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
CMS-10636 Partial County Justification Template Partial_County_Justification_Template_11042021 (2022 version 2).pdf	Form and Instruction
CMS-10636 LOI Group to NPI Matrix Template LOI Group to NPI matrix template.xlsx	Form
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
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
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
HPMS NMM Crosswalk 508 02072024.pdf HPMS NMM Crosswalk	IC Document
Provider HSD Table Crosswalk 508 02072024.pdf Provider HSD Table Crosswalk	IC Document
Provider HSD Table Crosswalk 508 02072024.pdf Provider HSD Table Crosswalk	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Three-Year Network Adequacy Review for Medicare Advantage Organizations

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422 Section 112(a)(1)(i) 42 CFR 422 Section 114(a)(3)(ii)

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
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

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: 502

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	2,753	2,753
Annual IC Time Burden (Hours)	27,470	27,470
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.