OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

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

ICR 201108-0938-004 · OMB 0938-0953 · Historical Active

Forms and Documents
Document
Name
Status
Form
 Modified
Form
 Modified
Supplementary Document
2011-08-22
Supporting Statement A
2011-11-21
IC Document Collections
IC ID
Document
Title
Status
8809 Modified
184965 Modified
ICR Details
0938-0953 201108-0938-004
Historical Active 200805-0938-009
HHS/CMS
Notice of Provider Non-Coverage (CMS-10123) and Detailed Explanation of Non-Coverage (CMS-10124)
Reinstatement with change of a previously approved collection   No
Regular
Approved with change 12/12/2011
Retrieve Notice of Action (NOA) 08/25/2011
  Inventory as of this Action Requested Previously Approved
12/31/2014 36 Months From Approved
5,339,849 0 0
927,931 0 0
0 0 0
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.
US Code: 42 USC 521 Name of Law: Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA)
   Statute at Large: 18 Stat. 1869 Name of Statute: null
   PL: Pub.L. 106 - 554 521 Name of Law: Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA)
   PL: Pub.L. 108 - 173 234 Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003
  
None
Not associated with rulemaking
  76 FR 18222 04/01/2011
76 FR 40369 07/08/2011
No
  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 5,339,849 0 0 0 2,224,212 3,115,637
Annual Time Burden (Hours) 927,931 0 0 0 405,793 522,138
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
Our revised methodology for calculating the NOMNC burden is responsible for the increase in our estimated managed care burden. We now calculate the managed care NOMNC burden based on the actual number of HHA and SNF services and discharges. This is consistent with how we have calculated the burden for Original Medicare NOMNCs in the previous two OMB collections. In addition, we are now including SNF data in our calculations for Original Medicare. This increases our burden by 2 million NOMNCs.
$0
No
No
No
No
No
Uncollected
William Parham 4107864669
  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
08/25/2011