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

Forms and Documents

Document Name	Status
Form CMMS-10124 Notice of Provider Non-Coverage (CMS-10123) and Detailed Explanation of Non-Coverage (CMS-10124) Form	Modified
0938-0953.Justification of Non-material change.docx Justification for No Material/Nonsubstantive Change	2011-12-14
CMS-10123-10124.Supporting Statement Part A.docx Supporting Statement A	2011-12-14

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) Form	Modified

ICR Details

OMB Control No: 0938-0953	ICR Reference No: 201112-0938-003
Status: Historical Active	Previous ICR Reference No: 201108-0938-004
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: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/15/2011
	Date Received in OIRA: 12/14/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2014	12/31/2014	12/31/2014
Responses	5,339,849	0	5,339,849
Time Burden (Hours)	927,931	0	927,931
Cost Burden (Dollars)	0	0	0

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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.

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Authorizing Statute(s): 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
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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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-10123, CMS-10123	Notice of Medicare Non-Coverage ,   Notice of Medicare Non-Coverage
Notice of Provider Non-Coverage (CMS-10123) and Detailed Explanation of Non-Coverage (CMS-10124)	CMMS-10124, CMS-10124	Detailed Explanation of Non-coverage ,   Detailed Explanation of Non-coverage

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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	5,339,849	5,339,849	0	0	0	0
Annual Time Burden (Hours)	927,931	927,931	0	0	0	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:

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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]? 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? Uncollected

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Common Form ICR:  No

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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: 12/14/2011

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