Crosswalk

Revisions to Form CMS-10287 MEDICARE QUALITY OF CARE COMPLAINT FORM
Action to be
Performed

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Reason for the Change

Include the Beneficiary’s
Medicare (HICN) number if
known.

Include the Beneficiary’s Medicare
Beneficiary Identifier (MBI)
number if known

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“Please
note”
section 1
and 2.

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Please note: If you raise
concerns that are not quality
of care concerns within the
scope of the QIO’s authority,
your complaint will be
referred to the appropriate
entity.
1.
By signing the form,
you are authorizing the QIO

When the QIO reviews your
complaint as a general quality of
care review, after you answered NO
to item 8, you may not receive
report of the review.
If you leave item 9 question blank, a
surveyor may contact you about
your satisfaction.
By signing the form, you are
authorizing the QIO to review your
complaint and render a formal
determination.
Please note:
• The processing of your
complaint may require the
requesting of pertinent
medical records.
• PLEASE keep this page for
your information. Only mail
the second page (Medicare

The Medicare Access and CHIP
Reauthorization Act (MACRA) of
2015 requires CMS to remove Social
Security Numbers from all Medicare
cards by April 2019. A new
randomly generated Medicare
Beneficiary Identifier (MBI) will
replace the SSN-based Health
Insurance Claim Number on new
Medicare cards for transactions like
billing, eligibility status, and claim
status.
Clarification is given in information
page about the implication of
reviewing a complaint as a general
quality of care review.
Clarification is given in information
page about the implication of leaving
item 9 blank.
Added to provide clarification about
the implication of signing the form.

Revised for more clarity, and to
remove duplicate statements.

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9

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to review your complaint and
Quality of Care Complaint
render a formal determination.
Form) to the QIO.
The processing of your
complaint may require the
requesting of pertinent
medical records.
2.
PLEASE keep this
page for your information.
Only mail the second page
(Medicare Quality of Care
Complaint Form) to the QIO.
MEDICARE NUMBER
MEDICARE BENEFICIARY
(HIC)
IDENTIFIER (MBI)
NUMBER
Check “yes” here if you
authorize the QIO to
forward your address or
other contact information to
the entity that conducts
beneficiary satisfaction
surveys. If you check “yes”,
you will be contacted by
telephone or postal mail to
conduct a brief survey about
your satisfaction with the
service you received from the
QIO. If you leave this
question blank, a surveyor
will contact you about your
satisfaction.

Check “yes” here if you authorize
the QIO to forward your address
or other contact information to
the entity that conducts
beneficiary satisfaction surveys. If
you check “yes” or leave this
question blank, you may be
contacted to conduct a brief survey
about your satisfaction with the
service you received from the QIO.

Revised for clarification
purposes, to ensure beneficiary
is certain the number that is
needed.
Revised for clarification purposes,
and to modify the language to
accommodate other forms of surveys
than by phone and postage.

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