Information Collection

Reporting Appeals and Grievance Data

IC 46763 under ICR 201910-0938-007 · OMB 0938-0778.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0778 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-R-0282 Data Form_2020_v508.pdf	Other-Sample Report
CMS-R-0282_Data Form Instructions_2020_v508.pdf	Instruction

IC Title:

Reporting 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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Sample Report			CMS-R-0282 Data Form_2020_v508.pdf		Yes	No	Printable Only
Instruction			CMS-R-0282_Data Form Instructions_2020_v508.pdf		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 733

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	58,400	3,100	55,300
Annual IC Time Burden (Hours)	4,672	248	4,424
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.