Information Collection

Dispute Resolution and Correction (Physicians)

IC 212216 under ICR 202112-0938-008 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10495 Dispute Resolution and Correction (Physicians)	Form and Instruction
CMS-10495 Review and Dispute Screen Shots CMS-10495 - Review And Dispute Screen Shots 9.23.2020 - 508 cf.pdf	Form and Instruction
CMS-10495 Review and Dispute Email Notifications CMS-10495 - Review_and_Dispute_Email_Notifications 9.23.2020 - 508 cf.pdf	Form and Instruction

IC Title:

Dispute Resolution and Correction (Physicians)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 403.908

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
Form and Instruction	CMS-10495	Review and Dispute Screen Shots	CMS-10495 - Review And Dispute Screen Shots 9.23.2020 - 508 cf.pdf		Yes	Yes	Fillable Fileable Signable
Form and Instruction	CMS-10495	Review and Dispute Email Notifications	CMS-10495 - Review_and_Dispute_Email_Notifications 9.23.2020 - 508 cf.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 31,897

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	31,897	31,897
Annual IC Time Burden (Hours)	114,510	114,510
Annual IC Cost Burden (Dollars)	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.