The Annual Medicare Contractor Provider Satisfaction Survey (MCPSS): (CMS-10097)

Medicare Contractor Provider Satisfaction Survey (MCPSS) and Supporting Regulations in 42 CFR 421.120 and 421.122

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0915 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10097 The Annual Medicare Contractor Provider Satisfaction Survey (MCPSS): (CMS-10097) Form and Instruction
ATTACHMENT 3 - REDLINED SURVEY INSTRUMENT.doc Other-Redline of Survey Instrument
ATTACHMENT 1 - SAMPLE DESIGN.xlsm Other-Sample Design
CMS-10097 MCPSS National Implementation 2009 Survey Instrument ATTACHMENT 2 - SURVEY INSTRUMENT.doc Form and Instruction
ATTACHMENT 4 - EXAMPLE OF COG INTVW.docm ATTACHMENT 4 - EXAMPLE OF COG INTVW IC Document
ATTACHMENT 5 - DATA ANALYSIS.docm ATTACHMENT 5 - DATA ANALYSIS IC Document
Change Summary.pdf Change Summary IC Document

Information Collection (IC) Details

IC Title:	The Annual Medicare Contractor Provider Satisfaction Survey (MCPSS): (CMS-10097)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 421.120 42 CFR 421.122 42 CFR 421.201

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10097	MCPSS National Implementation 2009 Survey Instrument	ATTACHMENT 2 - SURVEY INSTRUMENT.doc	Yes	Yes	Paper Only
Other-Redline of Survey Instrument			ATTACHMENT 3 - REDLINED SURVEY INSTRUMENT.doc	Yes	Yes	Paper Only
Other-Sample Design			ATTACHMENT 1 - SAMPLE DESIGN.xlsm	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 24,279	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: 90 %

	Approved	Previously Approved
Annual Number of Responses for this IC	24,279	24,279
Annual IC Time Burden (Hours)	8,346	8,346
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
ATTACHMENT 4 - EXAMPLE OF COG INTVW	ATTACHMENT 4 - EXAMPLE OF COG INTVW.docm	07/23/2008
ATTACHMENT 5 - DATA ANALYSIS	ATTACHMENT 5 - DATA ANALYSIS.docm	07/23/2008
Change Summary	Change Summary.pdf	07/23/2008

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.