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

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (CMS-10415)

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Medicare Administrative Contactors Customer Experience – Medical Review (CMS-10763)	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	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

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.