"Detailed Explanation of Non-Coverage and Notice of Medicare Non-Coverage" and Supporting Regulations in 42 CFR 422.626(e)(1) and 42 CFR 422.624(b)(1)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10095 DENC "Detailed Explanation of Non-Coverage and Notice of Medicare Non-Coverage" and Supporting Regulations in 42 CFR 422.626(e)(1) and 42 CFR 422.624(b)(1)	Form	Modified	Available
Form CMS-10095 DENC "Detailed Explanation of Non-Coverage and Notice of Medicare Non-Coverage" and Supporting Regulations in 42 CFR 422.626(e)(1) and 42 CFR 422.624(b)(1)	Form	New	Available
CMS-10095 suppstateMA Expedited appealsfinal121906.doc	Supporting Statement A	Uploaded 0000-00-00	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8750	"Detailed Explanation of Non-Coverage and Notice of Medicare Non-Coverage" and Supporting Regulations in 42 CFR 422.626(e)(1) and 42 CFR 422.624(b)(1)	Form	Modified
179179	"Detailed Explanation of Non-Coverage and Notice of Medicare Non-Coverage" and Supporting Regulations in 42 CFR 422.626(e)(1) and 42 CFR 422.624(b)(1)	Form	New

ICR Details

OMB Control No: 0938-0910	ICR Reference No: 200703-0938-013
Status: Historical Active	Previous ICR Reference No: 200311-0938-008
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: "Detailed Explanation of Non-Coverage and Notice of Medicare Non-Coverage" and Supporting Regulations in 42 CFR 422.626(e)(1) and 42 CFR 422.624(b)(1)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/23/2007
	Date Received in OIRA: 03/23/2007
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2010	36 Months From Approved	08/31/2007
Responses	47,558	0	612,000
Time Burden (Hours)	23,780	0	68,000
Cost Burden (Dollars)	0	0	0

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Abstract: Pursuant to 42 CFR 422.624(b)(1), providers in skilled nursing facilities, home health agencies and comprehensive outpatient rehabilitation facilities must deliver to MA enrollees a 2-day advance notice of termination of services. Per requirements at 42 CFR 422.626(e)(1), MA 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. 42 CFR 417.600(b) provides that cost plans must follow these same fast track appeal notification procedures for their enrollees in SNFs HHAs and CORFs.

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Authorizing Statute(s): PL: Pub.L. 108 - 173 234 Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003
   US Code: 42 USC 1395-21 Name of Law: Implementation of Medicare Advantage Program
  

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
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 1536	01/12/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 13793	03/23/2007
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
"Detailed Explanation of Non-Coverage and Notice of Medicare Non-Coverage" and Supporting Regulations in 42 CFR 422.626(e)(1) and 42 CFR 422.624(b)(1)	CMS-10095 DENC, CMS-10095 NOMNC	Detailed Explanation of Non-Coverage ,   Notice of Medicare Non-Coverage
"Detailed Explanation of Non-Coverage and Notice of Medicare Non-Coverage" and Supporting Regulations in 42 CFR 422.626(e)(1) and 42 CFR 422.624(b)(1)	CMS-10095 DENC, CMS-10095 NOMNC	Detailed Explanation of Non-Coverage ,   Notice of Medicare Non-Coverage

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ICR Summary of Burden

table that charts list 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	47,558	612,000	0	0	-564,442	0
Annual Time Burden (Hours)	23,780	68,000	0	0	-44,220	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: During the initial certification of the NOMNC and DENC notices, we had no ability to determine the impact of the fast track notification process on MA organizations and providers. Although we now have actual data regarding the use of the process, we still do not know the number of providers required to deliver the NOMNC on behalf of MA organizations. Since CMS holds the MA organization liable and responsible for delivery of all notices, and compliance with the regulations governing the fast track appeal process, we decided to account for that burden only in this package. The change in burden numbers then, is due to reliance on actual appeals data gathered since implementation of the fast track process from MA organizations only. Additionally, the change in burden is due to the increase in the hourly rate for individuals responsible for collecting and formatting the appeals information (from 2003 wages to 2006 wages) in MA organizations.

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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]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

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: 03/23/2007

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