Download:
pdf |
pdfOMB control number: 0938-1415
Expiration Date: XX/XX/20XX
ECP/NA Template Screenshots
ECP/NA Template - User Control Tab:
PRA DISCLOSURE: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
0938-1415, expiration date is XX/XX/20XX. The time required to complete this information collection is estimated to take up to
249,410 hours annually for all QHP and Stand-alone Dental issuers, including the time to review instructions, gather the
information needed, and complete and review the information collection. 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 Elizabeth Hechtman at [email protected].
ECP/NA Template – Select ECPs Tab:
ECP/NA Template – Facility ECPs Tab:
ECP/NA Template – Network Adequacy Provider Tab:
ECP/NA Template – Specialty Types Tab:
ECP/NA Template – Taxonomy Codes Tab:
ECP/NA Template –County Names Tab:
ECP/NA Template - Errors Tab:
| File Type | application/pdf |
| File Title | ECP/NA Template Screenshots |
| Subject | Centers for Medicare & Medicaid Services, ECP/NA Template Screenshots |
| Author | Centers for Medicare & Medicaid Services |
| File Modified | 2023-11-01 |
| File Created | 2023-10-27 |