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⚠️ Notice: This information collection may be referencing outdated material.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
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: Modified

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
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
Form	CMS-R-0282	Medicare Appeals and Quality of Care Grievances Sample Report	CMS-R-0282 Sample Form.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	Previously Approved
Annual Number of Responses for this IC	868	252	616
Annual IC Time Burden (Hours)	868	430	438
Annual IC Cost Burden (Dollars)	0	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.