Complaints Related to Surprise Billing

Complaints Submission Process under the No Surprises Act (CMS-10779)

Documents and Forms

Document Name Document Type
Form CMS-10779 Complaints Related to Surprise Billing Form and Instruction
CMS-10779 Consumer Complaint Form - No Surprises Help Desk CMS-10779.Consumer Complaint Form_No Surprises Help Desk.docx Form and Instruction
CMS-10779 Consumer Complaint Form - No Surprises Help Desk CMS-10779.Consumer Complaint Form_No Surprises Help Desk.docx Form and Instruction
CMS-10779 Provider Complaint Form - No Surprises Help Desk CMS-10779.Provider Complaint Form_No Surprises Help Desk.docx Form and Instruction
CMS-10779 Provider Complaint Form - No Surprises Help Desk Provider Complaint Form Help Desk Clean.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Complaints Related to Surprise Billing	Agency IC Tracking Number:

Is this a Common Form? Yes		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 149.450 45 CFR 149.150

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10779	Consumer Complaint Form - No Surprises Help Desk	CMS-10779.Consumer Complaint Form_No Surprises Help Desk.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10779	Provider Complaint Form - No Surprises Help Desk	Provider Complaint Form Help Desk Clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 39,000	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 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	39,000	37,200	1,800
Annual IC Time Burden (Hours)	19,500	18,600	900
Annual IC Cost Burden (Dollars)	1,055,730	1,007,004	48,726

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.