Request for Reconsideration of Part A Medicare Claim and Supporting Regulations in 42 CFR, 405.711

ICR 200310-0938-007

OMB: 0938-0045

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0045 200310-0938-007
Historical Active 200008-0938-008
HHS/CMS
Request for Reconsideration of Part A Medicare Claim and Supporting Regulations in 42 CFR, 405.711
Extension without change of a currently approved collection   No
Regular
Approved without change 11/14/2003
Retrieve Notice of Action (NOA) 10/16/2003
  Inventory as of this Action Requested Previously Approved
11/30/2006 11/30/2006 11/30/2003
60,000 0 62,000
15,000 0 15,500
0 0 0

Section 1869 of the Social Security Act authorizes a hearing for any individual who is dissatisfied with the intermediary's determination of amount of benefit paid. This form is used so that a party may request a reconsideration of the initial determination.

None
None


No

1
IC Title Form No. Form Name
Request for Reconsideration of Part A Medicare Claim and Supporting Regulations in 42 CFR, 405.711 CMS-2649

  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 60,000 62,000 0 0 -2,000 0
Annual Time Burden (Hours) 15,000 15,500 0 0 -500 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
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.
10/16/2003


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