Notice of Provider Non-Coverage (CMS-10123) and Detailed Explanation of Non-Coverage (CMS-10124)

ICR 200805-0938-009

OMB: 0938-0953

Federal Form Document

Forms and Documents
Document
Name
Status
Supplementary Document
2008-05-15
Supplementary Document
2008-05-15
Supporting Statement A
2008-07-14
ICR Details
0938-0953 200805-0938-009
Historical Active 200505-0938-004
HHS/CMS
Notice of Provider Non-Coverage (CMS-10123) and Detailed Explanation of Non-Coverage (CMS-10124)
Revision of a currently approved collection   No
Regular
Approved with change 07/15/2008
Retrieve Notice of Action (NOA) 05/19/2008
Supporting statement was revised to explain the change in burden.
  Inventory as of this Action Requested Previously Approved
07/31/2011 36 Months From Approved 07/31/2008
3,115,637 0 4,292,400
522,138 0 379,400
0 0 0

The Notice of Medicare Provider Non-Coverage (CMS-10123) is used to inform fee-for-service Medicare beneficiaries of the determination that their provider services will end, and of their right to an expedited review of that determination. The Detailed Explanation of Non-Coverage (CMS-10124) is used to provide beneficiaries who request an expedited determination with detailed information of why the services should end.

Statute at Large: 18 Stat. 1869 Name of Statute: null
   US Code: 42 USC 521 Name of Law: Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA)
  
None

0938-AL67 Final or interim final rulemaking 69 FR 227 11/26/2004

  73 FR 11119 02/29/2008
73 FR 26398 05/09/2008
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 3,115,637 4,292,400 0 0 -1,176,763 0
Annual Time Burden (Hours) 522,138 379,400 0 0 142,738 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Bonnie Harkless 4107865666

  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.
05/19/2008


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