Form CMS-10287 Crosswalk

Revisions to Form CMS-10287: Medicare Quality of Care Complaint Form
OMB-0938-1102
APPLICATION/UPDATE FORM
Issue
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2.

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Section

Action to be
performed
Page 1 of the
Delete text:
1. Check the
Medicare
appropriate box
QUALITY OF
indicating
CARE
whether you
COMPLAINT
would like the
FORM
physician or
provider who is
Information to
the subject of
Help You Fill
your complaint to
Out the
know that you
“Quality of
have filed a
Care
complaint with
Complaint”
the QIO about the
Form
care you
received. The
QIO will not
reveal your
identity if you
check “No.”

Changes to the Application

Reason for the Change

Replace:
Information about this will be in Question number
8. See below.

Per 42 CFR§ 476.160(a)(1) and
§1154 (a)(1)(B) of the SSA, Quality
Improvement Organizations have the
authority to conduct General Quality
of Care Reviews in instance when a
beneficiary wishes to remain
anonymous. If the beneficiary wishes
to remain anonymous, the complaint
cannot be processed as a written
beneficiary complaint. However, the
QIO may process the complaint as a
general quality of care review.

Page 2 of the
Medicare
Quality of Care
Complaint
Form

Replace:
8. May we review your identity during the review of
your complaint? Yes__ No __
If you check “no” we cannot review your compliant
as a written beneficiary compliant. However, based
on the circumstances of your complaint, we may
choose to review your complaint as a general
quality of care review.

Per 42 CFR§ 476.160(a)(1) and
§1154 (a)(1)(B) of the SSA, Quality
Improvement Organizations have the
authority to conduct General Quality
of Care Reviews in instance when a
beneficiary wishes to remain
anonymous. If the beneficiary wishes
to remain anonymous, the complaint
cannot be processed as a written

Original text as
follows:
8. May we review
your identity during
the review of your
complaint? Yes__
No___

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Issue
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3.

Page
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Section

Page 2 of the
Medicare
Quality of Care
Complaint
Form

Action to be
performed

Changes to the Application

Reason for the Change

beneficiary complaint. However, the
QIO may process the complaint as a
general quality of care review.
Add next text:
Currently at both intake and at the
9. Check yes here if you authorize the QIO to
end of their review, QIOs ask
forward your address or other contact information to beneficiaries whether they can mail
the entity that conducts beneficiary satisfaction
the beneficiary a satisfaction survey.
surveys? If you check “yes” below, the entity that
The process would be streamlined by
conducts beneficiary satisfaction surveys will mail
asking the beneficiary this question
you a survey in order to inquire about your level of
during intake of his/her complaint on
satisfaction with the service you received from the
the Medicare Quality of Care
QIO. If you leave this question blank, a QIO will Complaint Form. It also provides a
more accurate written, versus verbal
mail you a satisfaction survey.
Yes__ No__
response to the question of whether
the beneficiary wishes to be mailed a
satisfaction survey.

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