"Detailed Explanation of Non-Coverage" and "Important Medicare Message of Non-Coverage" and Supporting Regulations in 42 CFR 422.620, 422.624, and 422.626
ICR 200311-0938-008
OMB: 0938-0910
Federal Form Document
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0938-0910 can be found here:
"Detailed Explanation of
Non-Coverage" and "Important Medicare Message of Non-Coverage" and
Supporting Regulations in 42 CFR 422.620, 422.624, and 422.626
New
collection (Request for a new OMB Control Number)
This information
collection request is approved for a period of three years,
consistent with CMS' final rule entitled, "Medicare Program;
Improvements to the M+C Appeal and Grievance Procedures. The
request is approved as amended by CMS to respond to public
comments. CMS will provide OMB with a copy of the final version of
the notice. CMS is encouraged to continue to work with respondents
to reduce burden and improve the usefulness of the notice for
beneficiaries. Substantive changes to the notice will require OMB
approval.
Inventory as of this Action
Requested
Previously Approved
03/31/2007
03/31/2007
612,000
0
0
68,000
0
0
0
0
0
Pursuant to 42 CFR 422.624(b)(1),
providers in skilled nursing facilities, home health agencies and
comprehensive outpatient rehabilitation facilities must deliver to
M+C enrollees a 2-day advance notice of termination of services.
Per requirements at 42 CFR 422.626(e)(1), M+C organizations must
deliver detailed notices to the QIO and enrollees upon request for
appeal of the termination of services. These notices fulfill the
regulatory requirement.
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.