Information Collection

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

IC 46763 under ICR 201002-0938-005 · OMB 0938-0778.

⚠️ Notice: This information collection may be referencing outdated material.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 INSTRUCTIONS CMS-R-0282_508 version-01-07-2010.docx Instruction
CMS-R-0282 Medicare Appeals and Quality of Care Grievances CMS-R-0282 Sample Form508.pdf 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 422.111(c)(3)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			FORM INSTRUCTIONS CMS-R-0282_508 version-01-07-2010.docx		Yes	Yes	Paper Only
Form	CMS-R-0282	Medicare Appeals and Quality of Care Grievances	CMS-R-0282 Sample Form508.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 629	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	45,917	3,819	42,098
Annual IC Time Burden (Hours)	3,673	305	3,368
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.