Collecting Appeals and Grievance Data

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⚠️ Notice: This information collection may be referencing outdated material.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 INSTRUCTIONS CMS-R-0282-2012-CLEANv508.pdf Instruction
CMS-R-0282 Sample Form-2012-CLEANv508.pdf Other-Sample Report

Information Collection (IC) Details

IC Title:	Collecting Appeals and Grievance Data	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-0282-2012-CLEANv508.pdf		Yes	No	Printable Only
Other-Sample Report			CMS-R-0282 Sample Form-2012-CLEANv508.pdf		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 670	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	1,340	82	1,258
Annual IC Time Burden (Hours)	1,340	82	1,258
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.