State Innovation Models Initiative: Application Submission Guidance

In addition to this page, you may want to visit our Frequently Asked Questions (FAQ) page for guidance and information to help you complete your application.

Download screen shots of the 424 form being filled out (PDF).

The following information is being made available to provide additional guidance on the application submission process. Please note:

  • This document provides guidance on some, but not all elements of the application. Applicants should review the Funding Opportunity Announcement (FOA) and must submit all information listed in the FOA.
  • For technical questions on the application process through the website (e.g., uploading documents), please contact 800-518-4726 or Note: Please ask for a ticket number when speaking with a representative. The ticket number is not needed for the application, but it may be necessary should you need additional assistance in submitting your application.
  • For programmatic questions on the Initiative, please email Note: CMS may not have sufficient time to respond to programmatic questions received after September 19, 2012.
  • All applications must be submitted electronically and be received through by 5:00 pm Eastern Time on September 24, 2012.
  • To submit an application via, you will need the following:
    • Employer Identification Number (EIN), otherwise known as a Taxpayer Identification Number (TIN).
    • Dun and Bradstreet (D&B) Data Universal Numbering System (DUNS) number. The DUNS number is a nine-digit identification number that uniquely identifies business entities. Obtaining a DUNS number is easy and free. To obtain a DUNS number, access the following website: or call 1-866-705-5711. This number should be entered in the block 8c (on the Form SF-424, Application for Federal Assistance). The organization name and address entered in block 8a and 8d should be exactly as given for the DUNS number.
    • Registration in the System for Award Management (SAM) database at (Note: SAM replaces the former Central Contractor Registration (CCR) database.)
    • Authorized Organizational Representative. The Authorized Organizational Representative (AOR) who will officially submit an application on behalf of the organization must register with for a username and password. AORs must complete a profile with using their organization's DUNS Number to obtain their username and password. Please visit: AORs must wait at least one business day after registration in SAM before entering their profiles in When an AOR registers with to submit applications on behalf of an organization, that organization's E-Biz point-of-contact (POC) will receive an email notification. The email address provided in the profile will be the email used to send the notification from to the E-Biz point of contact (E-Biz POC) with the AOR copied on the correspondence. The E-Biz POC must then login to (using the organization's DUNS number for the username and the special password called "M-PIN") and approve the AOR, thereby providing permission to submit applications. The AOR and the DUNS must match. If your organization has more than one DUNS number, be sure you have the correct AOR for your application.
  • Please create three separate PDF files each in the order specified in the table below. Within each PDF please label and paginate each discrete document. For example, the Model Design Project Narrative in PDF #1 should be labeled and have page numbers 1 through 24. The Model Design Project Plan and Timeline, which is also part of PDF #1, should be labeled and have page numbers 1 through 3 (refer to FOA Chart 1: Application Package, Model Design Proposals [pg. 28] and Chart 2: Application Package, Model Testing Applications [pg. 30]). Please ensure that each PDF is a text searchable file rather than a scanned image.

Model Design

Model Test

PDF #1

Project Narrative (24 pages):

  • Model design strategy
  • Description of stakeholder engagement
  • Role of public and private payer participation
  • Project organization information
  • Provider Engagement

Project Plan and Timeline (3 pages)

PDF #1

Project Narrative (43 pages):

  • Model testing strategy
  • Description of expected engagement and transformation of major provider entities within the state
  • Evidence of other payers and stakeholders
  • Linkage to State Health Care Innovation Plan
  • Multi-Stakeholder engagement and commitment

Plan for Performance Reporting (5 pages)

Project Plan and Timeline (4 pages)

PDF #2:

Budget Narrative and itemized expenditure plan (5 pages)

PDF #2:

Budget Narrative and itemized expenditure plan (10 pages)

Other attachments PDF #3:

  • Governor's Letter if Endorsement (2 pages)
  • Financial Analysis
  • Letters of support and participation

Other attachments PDF #3:

  • Governor's Letter of Endorsement (2 pages)
  • State Health Care Innovation Plan
  • Financial Analysis
  • Letters of support and participation

In addition to providing the financial analysis as part of Other attachments PDF #3, please also email the spreadsheet in Excel file format to:

  • Please remember to follow the format requirements below:
    • Use 8.5" x 11" letter-size pages (one side only) with 1" margins (top, bottom and sides).
    • Font size must be 12-point.
    • Narrative portions of the application must be double-spaced.

Download screen shots of the 424 form being filled out (PDF).

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