Information Collection

Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408

IC 8163 under ICR 200705-0938-006 · OMB 0938-0566.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0566 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-R-131 30 NEW ABN PRA Instructions (2)tcec.doc	Instruction
CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN) CMS-R-131 New 07 ABN Draft post 60 (4).doc	Form
CMS-R-131 30 NEW ABN summary of changes (3)tcec.doc Summary of Changes	IC Document
New 07 ABN Draft post 60 (4)redline.doc Redline: Advance Beneficiary Notice of Noncoverage	IC Document
30 NEW ABN PRA Instructions (2)tcecredline.doc Redline: Instructions	IC Document

IC Title:

Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 411.404(b) and (c) 42 CFR 411.408(d)(2) and (f)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CMS-R-131 30 NEW ABN PRA Instructions (2)tcec.doc		Yes	Yes	Paper Only
Form	CMS-R-131	Advance Beneficiary Notice of Noncoverage (ABN)	CMS-R-131 New 07 ABN Draft post 60 (4).doc		Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,270,614

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	40,302,506	19,131,026	21,171,480
Annual IC Time Burden (Hours)	4,701,959	2,937,669	1,764,290
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Summary of Changes	CMS-R-131 30 NEW ABN summary of changes (3)tcec.doc	05/16/2007
Redline: Advance Beneficiary Notice of Noncoverage	New 07 ABN Draft post 60 (4)redline.doc	05/16/2007
Redline: Instructions	30 NEW ABN PRA Instructions (2)tcecredline.doc	05/16/2007

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.