Information Collection

Program Audits

IC 242155 under ICR 202606-0938-024 · OMB 0938-1395.

Documents and Forms
Document Name
Document Type
Form
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form
Form and Instruction
Form and Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Form
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Program Audits
 
No Modified
 
Mandatory
 
42 CFR 423.514 42 CFR 422.504 42 CFR 423.505

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction CPEProtocol.docx Yes Yes Printable Only
Instruction FAProtocol.docx Yes Yes Printable Only
Instruction CDAG Protocol.docx Yes Yes Printable Only
Instruction ODAGProtocol.docx Yes Yes Printable Only
Instruction SNPCCProtocol.docx Yes Yes Printable Only
Form CMS-10717 Pre Audit Issue Summary PreAuditIssueSummary.docx Yes Yes Fillable Printable
Form and Instruction CMS-10717 Compliance Program Effectiveness (CPE) Compliance Oversight Questionnaire CPEQuestionnaire.docx Yes Yes Fillable Printable
Form and Instruction CMS-10717 Compliance Program Effectiveness (CPE) Customized Organizational Structure and Governance PowerPoint Presentation CPEPowerPointPresentation.docx Yes Yes Fillable Printable
Form and Instruction CMS-10717 Part D Formulary and Benefit Administration (FA) Supplemental Questionnaire FAQuestionnaire.docx Yes Yes Fillable Printable
Form and Instruction CMS-10717 Special Needs Plans - Care Coordination Supplemental Questionnaire SNPCCQuestionnaire.docx Yes Yes Fillable Printable
Form and Instruction CMS-10717 Part D Coverage Determinations, Appeals, and Grievances (CDAG) Processing of Coverage Requests Root Cause Analysis and Impact Analysis CDAGPCRImpact.xlsx Yes Yes Fillable Printable
Form and Instruction CMS-10717 Part D Coverage Determinations, Appeals, and Grievances (CDAG) Classification of Requests Root Cause Analysis and Impact Analysis CDAGCRImpact.xlsx Yes Yes Fillable Printable
Form and Instruction CMS-10717 Special Needs Plans Care Coordination (SNPCC) Root Cause Analysis and Impact Analysis SNPCCImpact.xlsx Yes Yes Fillable Printable
Form and Instruction CMS-10717 Special Needs Plans Care Coordination (SNPCC) HRA Timeliness Mitigation Analysis (HRA-TMA) SNPCC HRATMA.xlsx Yes Yes Fillable Printable
Form and Instruction CMS-10717 Part C Organization Determinations, Appeals, and Grievances (ODAG) Processing of Coverage Requests Root Cause Analysis and Impact Analysis ODAGPCRImpact.xlsx Yes Yes Fillable Printable
Form and Instruction CMS-10717 Part C Organization Determinations, Appeals, and Grievances (ODAG)Classification of Requests Root Cause Analysis and Impact Analysis ODAGCRImpact.xlsx Yes Yes Fillable Printable
Form and Instruction CMS-10717 Organization Determinations, Appeals, and Grievances (ODAG) ODAG Timeliness Mitigation Analysis (ODAG-TMA) ODAGTimelinessMT.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10717 Formulary and Benefits Administration (FA) Root Cause Analysis and Impact Analysis FAEnrolleeImpact.xlsx Yes Yes Fillable Printable
Form and Instruction CMS-10717 Root Cause Analysis RootCauseAnalysisTemplate.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10717 Independent Validation Audit Work Plan IndependentValidationAWP.docx Yes Yes Fillable Fileable
Form CMS-10717 Attendance Log for Meetings/Webinars/Conferences AttendanceLogTemplate.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10717 CMS Request for Additional Information (RAI)/Sponsor Response ProgramAuditCMSRAI.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10717 Independent Validation Auditor (IVA) Validation Report IndependentValidationART.docx Yes Yes Fillable Fileable

Health Health Care Services

 

30 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  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 30 0 5 0 0 25
Annual IC Time Burden (Hours) 12,795 0 -4,730 0 0 17,525
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Formulary and Benefit Administration (FA) - Track change version FAProtocol SPM updated 060326 TRACKED.pdf 06/30/2026
Independent Validation Audit Work Plan - Track Change version IndependentValidationAWP _TrackChange.pdf 06/30/2026
Organization Determinations, Appeals, and Grievances - Track Change version ODAGProtocol Track Changes Version.pdf 06/30/2026
Special Needs Plans Care Coordination - Track change SNPCCProtocol Tracked changes.pdf 06/30/2026
Part C and Part D Compliance Program Effectiveness - Track change CPEProtocol 5 21-redlined .pdf 06/30/2026
CDAG_Program Audit Protocol - Track Change CDAG Protocol Master Track Changes Version.pdf 06/30/2026
CDAG_Processing of Coverage Requests Root Cause Analysis and Impact Analysi - Track Change CDAGPCRImpact_TC.pdf 06/30/2026
CDAG_Root Cause Analysis and Impact Analysis - Track Change CDAGCRImpact_TC.pdf 06/30/2026
RootCauseAnalysis - Track Change RootCauseAnalysisTemplate_TC.pdf 06/30/2026
Formulary and Benefits Administration (FA) Root Cause Analysis and Impact Analysis - Track Change FAEnrolleeImpact Updated 060426 TRACKED.pdf 06/30/2026
ODAG_Processing of Coverage Requests Root Cause Analysis and Impact Analysis - Track Change ODAGPCRImpact_TC.pdf 06/30/2026
ODAG_Root Cause Analysis and Impact Analysis - Track Change ODAGCRImpact_TC.pdf 06/30/2026
SNPCC-HRA-TMA - Track Change SNPCC HRATMA Tracked changes.xlsx 06/30/2026
SNPCC-Root Cause Analysis and Impact Analysis - Track Change SNPCCImpact Tracked changes.xlsx 06/30/2026
            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].