Detailed Explanation of Non-Coverage (42 CFR 422.626(e)(1)), and Notice of Medicare Non-Coverage (42 CFR 422.624(b)(1))

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Crosswalk -- Changes to NOMNC-DENC - 2010-FINAL.docx	Supplementary Document	Uploaded 2010-07-30	Repair queued
Comment Response.docx	Supplementary Document	Uploaded 2010-07-30	Available
NOMNCtrackchanges508.docx	Supplementary Document	Uploaded 2010-07-30	Available
NOMNCforminstructionstrackchanges508.docx	Supplementary Document	Uploaded 2010-07-30	Repair queued
DENCtrack changes508.docx	Supplementary Document	Uploaded 2010-07-30	Available
DENCforminstructionstrackchanges508.docx	Supplementary Document	Uploaded 2010-07-30	Repair queued
Supporting Statement - CMS-10095508 - 2010.doc	Supporting Statement A	Uploaded 2010-07-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8750	Detailed Explanation of Non-Coverage (42 CFR 422.626(e)(1)): DENC	Instruction	Modified
179179	Notice of Medicare Non-Coverage (42 CFR 422.624(b)(1)) : NOMNC (CMS-10095)	Instruction	Modified

ICR Details

OMB Control No: 0938-0910	ICR Reference No: 201008-0938-004
Status: Historical Active	Previous ICR Reference No: 200902-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Detailed Explanation of Non-Coverage (42 CFR 422.626(e)(1)), and Notice of Medicare Non-Coverage (42 CFR 422.624(b)(1))
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/29/2010
	Date Received in OIRA: 08/10/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2013	36 Months From Approved	10/31/2010
Responses	100,785	0	47,558
Time Burden (Hours)	45,353	0	23,780
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): US Code: 42 USC 1395-21 Name of Law: Implementation of Medicare Advantage Program
   PL: Pub.L. 108 - 173 234 Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003
  

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:
	75 FR 22810	04/30/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 43168	07/23/2010
Did the Agency receive public comments on this ICR? Yes

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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 (42 CFR 422.626(e)(1)): DENC	CMS-10095-DENC	Detailed Explanation of Non-coverage
Notice of Medicare Non-Coverage (42 CFR 422.624(b)(1)) : NOMNC (CMS-10095)	CMS-10095-NOMNC	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	100,785	47,558	0	42,582	10,645	0
Annual Time Burden (Hours)	45,353	23,780	0	10,645	10,928	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: No

Burden Reduction Due to:

Short Statement: Our revised methodology for calculating the total burden is responsible, in part, for the increase in burden for this package. We now include the total number of affected providers in our estimates, whereas we previously only included the total number of Medicare health plans. Additionally, the number of Medicare health plans has grown from 376 to 740 plans, the number of Medicare enrollees has increased from 6.1 million to 10.9 million, and the hourly wage for a GS-12, Step 1 employees has increased from $26.53 to $28.88. Please see Supporting Statement for further details concerning the increase in burden for this package.

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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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 08/10/2010

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