Medicare Quality of Care Complaint Form (CMS-10287)

Forms and Documents

Document Name	Status
Form CMS-10287 Medicare Quality of Care Complaint Form Form and Instruction	Modified
CMS-10287 Supporting Statement - Final 5-10-17.docx Supporting Statement A	2017-05-10

IC Document Collections

IC ID	Document Title	Status
191138	Medicare Quality of Care Complaint Form Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1102	ICR Reference No: 202007-0938-009
Status: Received in OIRA	Previous ICR Reference No: 201611-0938-013
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Medicare Quality of Care Complaint Form (CMS-10287)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 08/03/2020

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	4,350	0
Time Burden (Hours)	725	0
Cost Burden (Dollars)	0	0

---

Abstract: In accordance with Section 1154(a)(14) of the Social Security Act, QIOs are required to conduct appropriate reviews of all written complaints submitted by beneficiaries concerning the quality of care received. This form will establish a standard form for all beneficiaries to utilize and ensure pertinent information is obtained by QIOs to effectively process these complaints.

---

Authorizing Statute(s): US Code: 42 USC 1395c-3(a)(14) Name of Law: Functions of Peer Review Organizations
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 26479	05/04/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 46122	07/31/2020
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Medicare Quality of Care Complaint Form	CMS-10287	Medicare QUALITY OF CARE COMPLAINT FORM

---

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	4,350	0	0	0	0	4,350
Annual Time Burden (Hours)	725	0	0	0	0	725
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/03/2020

---