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OMB Control No: 0938-1177	ICR Reference No: 202607-0938-009
Status: Received in OIRA	Previous ICR Reference No: 202310-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Beneficiary and Family Centered Data Collection (CMS-10393)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 07/27/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	01/31/2027
Responses	9,000	9,000
Time Burden (Hours)	2,250	2,250
Cost Burden (Dollars)	31,365	31,365

Abstract: Information collection activities for the Beneficiary and Family Centered Information Collection include the following: Experience Survey: The population is comprised of Medicare beneficiaries who received support from a QIO with an appeal or complaint case. The sample will be stratified, analyzed, and reported by case type: • Appeal stratum – A simple random sample will be drawn of approximately 3 percent (9,000) of the annual universe (n=350,000). No sub-stratum oversampling will be used. This is expected to yield sufficient data to support quarterly analytic and evaluation reporting. • Complaint medical record review stratum - Given the relatively small annual volume (n=1,500), a census will be drawn in order to yield sufficient data for quarterly analytic and evaluation reporting. • Immediate advocacy stratum - A simple random sample will be drawn of approximately 30 percent (4,500) of the annual universe (n=15,000). No sub-stratum oversampling will be used. This is expected to yield sufficient data for quarterly analytic and evaluation reporting. Information collection will be conducted via telephone with paper surveys sent by mail upon request, and for those who do not respond by telephone. Data will be collected monthly with the annualized sample and burden hours allocated evenly across 12 months.

Authorizing Statute(s): US Code: 42 USC 1320c 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:
	91 FR 24872	05/07/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 46785	07/24/2026
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 Beneficiary and Family-Centered Satisfaction Survey	CMS-10393

ICR Summary of Burden

	Total Request	Previously Approved
Annual Number of Responses	9,000	9,000
Annual Time Burden (Hours)	2,250	2,250
Annual Cost Burden (Dollars)	31,365	31,365

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: $4,299

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

Agency Contact: Denise King 410 786-1013 Denise.King@cms.hhs.gov

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