Medicare Advantage Quality Bonus Payment Demonstration MAO mail survey

Medicare Advantage Quality Bonus Payment Demonstration

Documents and Forms

Document Name Document Type
Form CMS-10445 Medicare Advantage Quality Bonus Payment Demonstration MAO mail survey Form and Instruction
CMS-10445 Initial Call Form Appendix C_Initial Call Form.docx Form and Instruction
CMS-10445 Reminder Call Script Appendix D_Reminder Call Script.docx Form and Instruction
CMS-10445 QBP MAO Survey QBP MAO Survey_02.01.2013_508.docx Form and Instruction
Appendix E_FAQ.docx FAQ IC Document
Appendix B_Letters to health plans.docx Letters to health plans IC Document

Information Collection (IC) Details

IC Title:	Medicare Advantage Quality Bonus Payment Demonstration MAO mail survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10445	Initial Call Form	Appendix C_Initial Call Form.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10445	Reminder Call Script	Appendix D_Reminder Call Script.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10445	QBP MAO Survey	QBP MAO Survey_02.01.2013_508.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 620	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	620	620
Annual IC Time Burden (Hours)	610	610
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
FAQ	Appendix E_FAQ.docx	02/25/2013
Letters to health plans	Appendix B_Letters to health plans.docx	02/25/2013

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