Appeals of Quality Bonus Payment Determinations

Quality Bonus Payment Appeals

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1129 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10346 Appeals of Quality Bonus Payment Determinations Form and Instruction
CMS-10346 Request for Reconsideration Request_For_Reconsideration_Form_2019.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Appeals of Quality Bonus Payment Determinations	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 422.260

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10346	Request for Reconsideration	Request_For_Reconsideration_Form_2019.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	20	-5	25
Annual IC Time Burden (Hours)	160	-40	200
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.