Information Collection

Essential Community Provider and Network Adequacy Data Requirements

IC 251109 under ICR 202408-0938-010 · OMB 0938-1415.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1415 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10803 Essential Community Provider and Network Adequacy Data Requirements	Form and Instruction
Form CMS-10803 Appendix A Essential Community Provider and Network Adequacy Data Requirements	Form and Instruction
CMS-10803_Appendix_B_ECP-NA_Issuer_Module_Mockup_508.pdf	Other-Screenshots
CMS-10803 - Appendix_C_ECP_Screenshotsf.docx	Other-Screenshots
CMS-10803 Appendix A CMS-10803_Appendix_A_ECP-NA_Template_508.pdf	Form and Instruction
CMS-10803 Appendix A CMS-10803 - Appendix_A_Network_Adequacy_Template.docx	Form and Instruction
CMS-10803_Appendix_B_ECP-NA_Issuer_Module_Mockup_508.pdf Appendix B - User Module Mockup	IC Document

IC Title:

Essential Community Provider and Network Adequacy Data Requirements

Agency IC Tracking Number:

CMS-10803

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 156.235 45 CFR 156.230

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10803				Yes	Yes	Paper Only
Other-Screenshots					Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 365

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	365	-120	485
Annual IC Time Burden (Hours)	4,196	-1,184	5,380
Annual IC Cost Burden (Dollars)	316,583	316,583	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].