Notice of Provider Non-Coverage (CMS-10123) and Detailed Explanation of Non-Coverage (CMS-10124)

Forms and Documents

Document Name	Status
CROSSWALK DOC 020508 .doc Supplementary Document	2008-05-15
CROSSWALK DOC 020508 .doc Supplementary Document	2008-05-15
Rev[1]. Supporting Statement 7-11-08.doc Supporting Statement A	2008-07-14

IC Document Collections

IC ID	Document Title	Status
8809	Expedited Review Notices and Supporting Regulations Contained in 42 CFR SEction 405.1200 and 405.1202 Instruction	Modified
184965	Notice of Provider Non-Coverage (CMS-10123) and Detailed Explanation of Non-Coverage (CMS-10124) Instruction	New

ICR Details

OMB Control No: 0938-0953	ICR Reference No: 200805-0938-009
Status: Historical Active	Previous ICR Reference No: 200505-0938-004
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Notice of Provider Non-Coverage (CMS-10123) and Detailed Explanation of Non-Coverage (CMS-10124)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/15/2008
	Date Received in OIRA: 05/19/2008
Terms of Clearance: Supporting statement was revised to explain the change in burden.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2011	36 Months From Approved	07/31/2008
Responses	3,115,637	0	4,292,400
Time Burden (Hours)	522,138	0	379,400
Cost Burden (Dollars)	0	0	0

---

Abstract: The Notice of Medicare Provider Non-Coverage (CMS-10123) is used to inform fee-for-service Medicare beneficiaries of the determination that their provider services will end, and of their right to an expedited review of that determination. The Detailed Explanation of Non-Coverage (CMS-10124) is used to provide beneficiaries who request an expedited determination with detailed information of why the services should end.

---

Authorizing Statute(s): Statute at Large: 18 Stat. 1869 Name of Statute: null
   US Code: 42 USC 521 Name of Law: Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA)
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AL67	Final or interim final rulemaking	69 FR 227	11/26/2004

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 11119	02/29/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 26398	05/09/2008
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Expedited Review Notices and Supporting Regulations Contained in 42 CFR SEction 405.1200 and 405.1202	CMS-10124, CMS-10124, CMS-10123, CMS-10123	Detailed Explanation of Non-coverage ,   Detailed Explanation of Non-Coverage (Redline) ,   Notice of Medicare Provider Non-Coverage ,   Notice of Medicare Provider Non-Coverage (Redline
Notice of Provider Non-Coverage (CMS-10123) and Detailed Explanation of Non-Coverage (CMS-10124)	CMS-10124, CMS-10124, CMS-10123, CMS-10123	Detailed Explanation of Non-coverage ,   Detailed Explanation of Non-Coverage (Redline) ,   Notice of Medicare Provider Non-Coverage ,   Notice of Medicare Provider Non-Coverage (Redline

---

ICR Summary of Burden

	Total Approved	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	3,115,637	4,292,400	0	0	-1,176,763	0
Annual Time Burden (Hours)	522,138	379,400	0	0	142,738	0
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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

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: 05/19/2008

---