Medicare+Choice Appeal Notices, "Notice of Denial of Medical Coverage", "Notice of Denial of Payment" and supporting regulations in 42 CFR 422.568

ICR 200403-0938-004

OMB: 0938-0829

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0829 200403-0938-004
Historical Active 200103-0938-007
HHS/CMS
Medicare+Choice Appeal Notices, "Notice of Denial of Medical Coverage", "Notice of Denial of Payment" and supporting regulations in 42 CFR 422.568
Extension without change of a currently approved collection   No
Regular
Approved without change 05/28/2004
Retrieve Notice of Action (NOA) 03/17/2004
  Inventory as of this Action Requested Previously Approved
05/31/2007 05/31/2007 05/31/2004
71,200 0 29,892
7,120 0 2,994
0 0 0

Section 1852(g)(1)(B) requies M+C organizations to provide determinations to deny coverage (i.e., medical services or payment) in writing and include a statement in understandable language of the reasons for the denial and a description of the reconsideration and appeals processes. These notices fulfill the statutory requirement.

None
None


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 71,200 29,892 0 0 41,308 0
Annual Time Burden (Hours) 7,120 2,994 0 0 4,126 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.
03/17/2004


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