Reporting Appeals and Grievance Data

Medicare Health Plan Appeals and Grievance Data Collection and Reporting Requirements, Data Disclosure Requirements under section 422.111 (CMS-R-282)

Documents and Forms

Document Name Document Type
CMS-R-0282 Data Form_2023_v508.pdf Other-Sample Report
CMS-R-0282 Data Form_2023_.docx Other-Sample Report
CMS-R-0282_Data Form Instructions_2023_v508.pdf Instruction
CMS-R-0282_Data Form Instructions_2023_v508.pdf Instruction

Information Collection (IC) Details

IC Title:	Reporting Appeals and Grievance Data	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.111(c)(3)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Sample Report			CMS-R-0282 Data Form_2023_.docx		Yes	No	Printable Only
Instruction			CMS-R-0282_Data Form Instructions_2023_v508.pdf		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 940	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	62,800	4,400	58,400
Annual IC Time Burden (Hours)	5,024	352	4,672
Annual IC Cost Burden (Dollars)	0	0	0

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.