Information Collection

Three-Year Network Adequacy Review for Medicare Advantage Organizations

IC 227912 under ICR 202412-0938-004 · OMB 0938-1346.

Documents and Forms

Document Name Document Type
MA_Network_Adequacy_Guidance_4205-F_CLEAN.pdf Instruction
MA_Network_Adequacy_Guidance_4205-F_CLEAN.pdf Instruction
CMS-10636 Provider HSD Table MA_Provider_Table_Template NEW 508.pdf Form
CMS-10636 Provider HSD Table MA_Provider_Table_Template NEW 508.pdf Form
CMS-10636 Facility HSD Table MA_Facility_Table_Template NEW 508.pdf Form
CMS-10636 Facility HSD Table MA_Facility_Table_Template NEW 508.pdf Form
CMS-10636 Exception Request Template MA_Exception_Template_REVISED.pdf Form
CMS-10636 Exception Request Template MA_Exception_Template_REVISED.pdf Form
CMS-10636 Partial County Justification Template Partial_County_Justification_Template_(2022 version) NO CHANGES 508.pdf Form and Instruction
CMS-10636 Partial County Justification Template Partial_County_Justification_Template_(2022 version) NO CHANGES 508.pdf Form and Instruction
CMS-10636 HPMS Web Based Application: NMM Telehealth NMM Page Proposed Changes.pdf Form
CMS-10636 HPMS Web Based Application: NMM Telehealth NMM Page Proposed Changes.pdf Form
MA_Network_Adequacy_Guidance_4205-F_Track changes_03062024.pdf Redline: Network Adequacy Guidance IC Document
MA_Network_Adequacy_Guidance_4205-F_Track changes_03062024.pdf Redline: Network Adequacy Guidance IC Document
Provider HSD Table Crosswalk 508.pdf Crosswalk: Provider HSD Table IC Document
Provider HSD Table Crosswalk 508.pdf Crosswalk: Provider HSD Table IC Document
Facility HSD Table Crosswalk 508.pdf Crosswalk: Facility HSD Table Template IC Document
Facility HSD Table Crosswalk 508.pdf Crosswalk: Facility HSD Table Template IC Document
Exception Request Template Crosswalk.pdf Crosswalk: Exception Request Template IC Document
Exception Request Template Crosswalk.pdf Crosswalk: Exception Request Template IC Document
HPMS NMM Crosswalk.pdf Crosswalk: Network Management Module (NMM) IC Document
HPMS NMM Crosswalk.pdf Crosswalk: Network Management Module (NMM) 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 114(a)(3)(ii) 42 CFR 422 Section 112(a)(1)(i)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			MA_Network_Adequacy_Guidance_4205-F_CLEAN.pdf	Yes	No	Printable Only
Form	CMS-10636	Provider HSD Table	MA_Provider_Table_Template NEW 508.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10636	Facility HSD Table	MA_Facility_Table_Template NEW 508.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10636	Exception Request Template	MA_Exception_Template_REVISED.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10636	Partial County Justification Template	Partial_County_Justification_Template_(2022 version) NO CHANGES 508.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10636	HPMS Web Based Application: NMM	Telehealth NMM Page Proposed Changes.pdf	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 %

	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

Title	Document	Date Uploaded
Redline: Network Adequacy Guidance	MA_Network_Adequacy_Guidance_4205-F_Track changes_03062024.pdf	12/17/2024
Crosswalk: Provider HSD Table	Provider HSD Table Crosswalk 508.pdf	12/17/2024
Crosswalk: Facility HSD Table Template	Facility HSD Table Crosswalk 508.pdf	12/17/2024
Crosswalk: Exception Request Template	Exception Request Template Crosswalk.pdf	12/17/2024
Crosswalk: Network Management Module (NMM)	HPMS NMM Crosswalk.pdf	12/17/2024

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