Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Audit and Reimbursement (CMS-10812)

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

Documents and Forms

Document Name Document Type
Form CMS-10812 Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Audit and Reimbursement (CMS-10812) Form
CMS-10812 CMS-10812. Audit and Reimbursement - Website CMS-10812. Audit and Reimbursement - Website.docx Form
CMS-10812 CMS-10812. Audit and Reimbursement - Website CMS-10812. Audit and Reimbursement - Website.docx Form
CMS-10812 CMS-10812. Audit and Reimbursement - Letter CMS-10812. Audit and Reimbursement - Letter.docx Form
CMS-10812 CMS-10812. Audit and Reimbursement - Letter CMS-10812. Audit and Reimbursement - Letter.docx Form
CMS-10812. Audit and Reimbursement Fast Track Form.docx CMS-10812. Audit and Reimbursement Fast Track Form IC Document
CMS-10812. Audit and Reimbursement Fast Track Form.docx CMS-10812. Audit and Reimbursement Fast Track Form IC Document
CMS-10812. Link for PRA Disclosure Statement.pdf CMS-10812. Link for PRA Disclosure Statement IC Document
CMS-10812. Link for PRA Disclosure Statement.pdf CMS-10812. Link for PRA Disclosure Statement IC Document

Information Collection (IC) Details

IC Title:	Medicare Administrative Contractor (MAC) Customer Experience (MCE) Program – Audit and Reimbursement (CMS-10812)	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	CMS-10812	CMS-10812. Audit and Reimbursement - Website	CMS-10812. Audit and Reimbursement - Website.docx		Yes	Yes	Fillable Fileable
Form	CMS-10812	CMS-10812. Audit and Reimbursement - Letter	CMS-10812. Audit and Reimbursement - Letter.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: 09-90-1901 HHS Correspondence, Customer Service, and Contact List	FR Citation: 84 FR 28823

Number of Respondents: 5,000	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 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,000	5,000
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-10812. Audit and Reimbursement Fast Track Form	CMS-10812. Audit and Reimbursement Fast Track Form.docx	11/28/2022
CMS-10812. Link for PRA Disclosure Statement	CMS-10812. Link for PRA Disclosure Statement.pdf	11/28/2022

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