Limitation of Liability and Information Collection Requirements Referenced in 42 CFR 411.404(c)(2)+(3), 411.406(c)+(d)

ICR 199710-0938-003

OMB: 0938-0465

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0465 199710-0938-003
Historical Active 199408-0938-003
HHS/CMS
Limitation of Liability and Information Collection Requirements Referenced in 42 CFR 411.404(c)(2)+(3), 411.406(c)+(d)
Extension without change of a currently approved collection   No
Regular
Approved without change 11/18/1997
Retrieve Notice of Action (NOA) 10/09/1997
  Inventory as of this Action Requested Previously Approved
11/30/2000 11/30/2000 11/30/1997
2,898,104 0 8,075
241,509 0 1,346
0 0 0

The Medicare program requires the provision of written notification of noncovered services to beneficiaries by the providers, practitioners, and suppliers. The notification gives the beneficiary, provider, practitioner, or supplier knowledge that Medicare will not pay for items or services mentioned in the notification. After this notification, any future claim for the same or similar services will not be paid by the program and the affected parties will be liable for the noncovered services.

None
None


No

1
IC Title Form No. Form Name
Limitation of Liability and Information Collection Requirements Referenced in 42 CFR 411.404(c)(2)+(3), 411.406(c)+(d) HCFA-R-77

  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 2,898,104 8,075 0 2,890,029 0 0
Annual Time Burden (Hours) 241,509 1,346 0 240,163 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  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.
10/09/1997


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