Information Collection

Medicare Administrative Contactors Customer Experience – Medical Review (CMS-10763)

IC 257121 under ICR 202211-0938-011 · OMB 0938-1185.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10763 Medicare Administrative Contactors Customer Experience – Medical Review (CMS-10763)	Form and Instruction
CMS-10763 CMS-10763.Medical Review Survey - English final CMS-10763.Medical Review Survey - English final.docx	Form and Instruction
CMS-10763 CMS-10763.Medical Review Survey - English final CMS-10763.Medical Review Survey - English final.docx	Form and Instruction
CMS-10763 CMS-10763.Medical Review Survey - Spanish final CMS-10763.Medical Review Survey - Spanish final.docx	Form and Instruction
CMS-10763 CMS-10763.Medical Review Survey - Spanish final CMS-10763.Medical Review Survey - Spanish final.docx	Form and Instruction
CMS-10763.MR-TPE-Survey-Scenarios.docx CMS-10763.MR-TPE-Survey-Scenarios	IC Document
CMS-10763.MR-TPE-Survey-Scenarios.docx CMS-10763.MR-TPE-Survey-Scenarios	IC Document
CMS-10763.Final_MR_TPE_fast-track-PRA (1).docx CMS-10763.Final_MR_TPE_fast-track-PRA	IC Document
CMS-10763.Final_MR_TPE_fast-track-PRA (1).docx CMS-10763.Final_MR_TPE_fast-track-PRA	IC Document

IC Title:

Medicare Administrative Contactors Customer Experience â Medical Review (CMS-10763)

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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-10763	CMS-10763.Medical Review Survey - English final	CMS-10763.Medical Review Survey - English final.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10763	CMS-10763.Medical Review Survey - Spanish final	CMS-10763.Medical Review Survey - Spanish final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,000

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10763.MR-TPE-Survey-Scenarios	CMS-10763.MR-TPE-Survey-Scenarios.docx	11/25/2022
CMS-10763.Final_MR_TPE_fast-track-PRA	CMS-10763.Final_MR_TPE_fast-track-PRA (1).docx	11/25/2022

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.