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Tracking Face-to-Face Encounters (all SNP types)
Medicare Advantage Model of Care Submission Requirements (CMS-10565)
OMB: 0938-1296
IC ID: 247322
OMB.report
HHS/CMS
OMB 0938-1296
ICR 202506-0938-009
IC 247322
( )
Documents and Forms
Document Name
Document Type
Form CMS-10565
Tracking Face-to-Face Encounters (all SNP types)
Form
CMS-10565 Model of Care Requirements for Medicare Advantage Specia
Draft MOC Matrix Requirements.docx
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Tracking Face-to-Face Encounters (all SNP types)
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Mandatory
CFR Citation:
42 CFR 422.101(f)(1)(iv)
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CMS-10565
Model of Care Requirements for Medicare Advantage Special Needs Plans
Draft MOC Matrix Requirements.docx
Yes
Yes
Fillable Printable
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:
1,340
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:
0 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
1,340
0
606
0
734
0
Annual IC Time Burden (Hours)
5,360
0
2,424
0
2,936
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
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.