CMS-10636 Exception Request Template
Triennial Network Adequacy Review for Medicare Advantage Organizations and 1876 Cost Plans (CMS-10636)
MA_Exception_Request_Template_(CMS-4201-P version 1)
Three-Year Network Adequacy Review for Medicare Advantage Organizations
OMB: 0938-1346
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1346 can be found here: