Collecting Appeals and Grievance Data

Medicare Health Plan Appeals and Grievance Data Collection and Reporting Requirements, Data Disclosure Requirements under section 422.111 (CMS-R-282)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
CMS-R-0282_Data Form Instructions_2020_v508.pdf Instruction
CMS-R-0282 Data Form_2020_v508.pdf Other-Sample Report

Information Collection (IC) Details

IC Title:	Collecting 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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CMS-R-0282_Data Form Instructions_2020_v508.pdf		Yes	No	Printable Only
Other-Sample Report			CMS-R-0282 Data Form_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: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	733	-749	1,482
Annual IC Time Burden (Hours)	733	-749	1,482
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.