Information Collection

Dispute Resolution and Correction (Physicians)

IC 212216 under ICR 201407-0938-004 · OMB 0938-1237.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1237 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10495 Dispute Resolution and Correction (Physicians) Form and Instruction
CMS-10495 Dispute Resolution and Correction OPS_Review_and_Dispute_Wire and Emails_620 OMB FINAL.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Dispute Resolution and Correction (Physicians)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 403.908

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10495	Dispute Resolution and Correction	OPS_Review_and_Dispute_Wire and Emails_620 OMB FINAL.docx		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 224,425	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	224,425	224,425
Annual IC Time Burden (Hours)	1,346,550	1,346,550
Annual IC Cost Burden (Dollars)	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.