Information Collection

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

IC 257139 under ICR 202211-0938-011 · OMB 0938-1185.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.