Information Collection

Essential Community Provider and Network Adequacy Data Requirements

IC 251109 under ICR 202602-0938-012 · OMB 0938-1415.

Documents and Forms

Document Name Document Type
Form CMS-10803 Appendix A Essential Community Provider and Network Adequacy Data Requirements Form and Instruction
Form CMS-10803 Non-Network Plan Attestation - Questions Essential Community Provider and Network Adequacy Data Requirements Form
CMS-10803 - Appendix C - Screenshots.pdf Other-Screenshots
CMS-10803 Appendix A CMS-10803 - Appendix A - Template.pdf Form and Instruction
CMS-10803 Non-Network Plan Attestation - Questions CMS-10803 - Appendix D - Attestation.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

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 156.230 45 CFR 156.235

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10803	Appendix A	CMS-10803 - Appendix A - Template.pdf	Yes	Yes	Paper Only
Other-Screenshots			CMS-10803 - Appendix C - Screenshots.pdf	Yes	No	Paper Only
Form	CMS-10803	Non-Network Plan Attestation - Questions	CMS-10803 - Appendix D - Attestation.pdf	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 164	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	164	-201	365
Annual IC Time Burden (Hours)	3,280	-916	4,196
Annual IC Cost Burden (Dollars)	142,245	-174,338	316,583

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.

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