Medicare Quality of Care Complaint Form

Forms and Documents

Document Name	Status
Form CMS-10287 Medicare Quality of Care Complaint Form Form and Instruction	Modified
CMS-10287 Final Supporting Statement.docx Supporting Statement A	2013-11-20

IC Document Collections

IC ID	Document Title	Status
191138	Medicare Quality of Care Complaint Form Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1102	ICR Reference No: 201307-0938-023
Status: Historical Active	Previous ICR Reference No: 200910-0938-012
Agency/Subagency: HHS/CMS	Agency Tracking No: 20156
Title: Medicare Quality of Care Complaint Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/21/2013
	Date Received in OIRA: 07/30/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2016	36 Months From Approved	11/30/2013
Responses	3,500	0	3,500
Time Burden (Hours)	583	0	583
Cost Burden (Dollars)	0	0	0

---

Abstract: In accordance with Section 1154(a)(14) of the Social Security Act, QIOs are required to conduct appropriate reviews of all written complaints submitted by beneficiaries concerning the quality of care received. This form will establish a standard form for all beneficiaries to utilize and ensure pertinent information is obtained by QIOs to effectively process these complaints.

---

Authorizing Statute(s): US Code: 42 USC 1395c-3(a)(14) Name of Law: Functions of Peer Review Organizations
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 27400	05/10/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 44569	07/24/2013
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Medicare Quality of Care Complaint Form	CMS-10287, CMS-10287	Crosswalk ,   Medicare Quality of Care Complaint Form

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	3,500	3,500	0	0	0	0
Annual Time Burden (Hours)	583	583	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/30/2013

---