Medicare Health Plan Appeals and Grievance Data Collection and Reporting Requirements, Data Disclosure Requirements under section 422.111

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0778 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-R-0282 Medicare Health Plan Appeals and Grievance Data Collection and Reporting Requirements, Data Disclosure Requirements under section 422.111 Form
CMS-R-0282 FORM INSTRUCTIONS CMS-R-0282.doc Instruction
CMS-R-0282 Disclosure Statement.doc Other-Other
CMS-R-0282 Medicare Appeals and Quality of Care Grievances Sample R CMS-R-0282 Sample Form.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicare Health Plan Appeals and Grievance Data Collection and Reporting Requirements, Data Disclosure Requirements under section 422.111	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.422.111

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-R-0282	Medicare Appeals and Quality of Care Grievances Sample Report	CMS-R-0282 Sample Form.doc	Yes	Yes	Paper Only
Instruction			CMS-R-0282 FORM INSTRUCTIONS CMS-R-0282.doc	Yes	Yes	Paper Only
Other-Other			CMS-R-0282 Disclosure Statement.doc	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 434	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 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	42,098	42,098
Annual IC Time Burden (Hours)	3,368	3,368
Annual IC Cost Burden (Dollars)	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.