Crosswalk

Changes to CMS 10141/OMB 0938-0964 Crosswalk
2022 (old version)

2024 (new version)

Type of
Change
Add

Reason for
change
Accuracy

Burden
Change
No

Justification

Justification: To account for additions from
4201-F and 4205-F and change to the Preclusion
List Letter expiration date of (1/31/2028)

Introduction

Added information about 4201-F, 4205-F and
addition of new ICRs

Add

Accuracy

No

12.3 ICRs Regarding Medicare
Prescription Drug Benefit Program

Revised to identify new sections and revised
sections with appropriate updated costs and
burdens.

Rev

Accuracy

Yes

12.3 ICRs Regarding Medicare
Prescription Drug Benefit Program

Revised 12.3.11 to remove one-time burden
associated with establishing DMPs and initial
programming of standardized and model
communications.

Rev

Accuracy

Yes

12.3.27 Burden Summary

Revised Table 12 to reflect an accurate burden
summary subtotal

Rev

Accuracy

Yes

12.4.3 ICR Burden Summary

Revised Table 13 to reflect an accurate burden
summary subtotal

Rev

Accuracy

Yes

12.4.10 Dissemination of Plan
Information

Added new ICR to reflect changes to Formulary
Notices under 423.128

Rev

Accuracy

Yes

12.4.3 ICR Burden Summary

Revised Table 6 to reflect an accurate burden
summary subtotal and addition of Formulary
Changes ICR

Rev

Accuracy

Yes

12.5 ICR Burden Summary

Revised Table 14 and Table 15 to reflect an
accurate burden summary subtotal

Rev

Accuracy

Yes

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesignation.

2022 (old version)

2024 (new version)

Type of
Change
Rev

Reason for
change
Accuracy

Burden
Change
Yes

15.1 Non-rule Changes: Revisions

Revised 12.2 to adjust burden based on more
recent estimates for grievance procedures

15.1 Non-rule Changes: Revisions

Revised 12.3.11 to remove one-time burden
associated with establishing DMPs and initial
programming of standardized and model
communications.
Revised Table 16 to reflect an accurate burden
summary subtotal

Rev

Accuracy

Yes

Rev

Accuracy

Yes

15.2 Summary of Burden Changes

Added Table 17 to indicate changes to SEP ICR

Add

Accuracy

Yes

15.2 Summary of Burden Changes

Added Table 18 to indicate extraction of Part D
EOB ICR

Del

Accuracy

Yes

15.2 Summary of Burden Changes

Added Table 19 to reflect requirements for
Utilization Management Committee ICR

Add

Accuracy

Yes

15.2 Summary of Burden Changes

Added Table 20 to indicate extraction of DMP,
MTM, UM, and QA ICR

Add

Accuracy

Yes

PRA Disclosure Statement in Part C and
D Precluded Provider Letter Template

PRA Disclosure Statement in Part C and D
Precluded Provider Letter Template

Rev

Accuracy

No

According to the Paperwork Reduction
Act of 1995, no persons are required to
respond to a collection of information
unless it displays a valid OMB control
number. The valid OMB control number
for this collection is 0938-0964. The time
required to complete this information
collection is estimated to average 5

PRA Disclosure Statement According to the
Paperwork Reduction Act of 1995, no persons
are required to respond to a collection of
information unless it displays a valid OMB
control number. The valid OMB control number
for this information collection is [0938-0964].
This information collection is necessary to
ensure CMS follows up with a written notice

15.2 Summary of Burden Changes

minutes per response, including the time
to review instructions, search existing data
resources, and gather the data needed, and
complete and review the information
collection. If you have any 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, Baltimore, Maryland
21244-1850.

OMB Approval No. 0938-0964 (Expires
1/31/2025)

through certified mail to the impacted provider
in advance of his or her inclusion on the
Preclusion List and their applicable appeal
rights. The time required to complete this
information collection is estimated to average
less than 5 minutes per response, including the
time to review instructions, search existing data
resources, gather the data needed, to review and
complete the information collection. This
information collection is mandatory as outlined
under CFR §423.120(c)(6)). 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.
OMB Approval No. 0938-0964 (Expires
1/31/2028)

Rev

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesignation.

Accuracy

No