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

Document Name	Status
CMS-10095-NOMNC508-2010 spa_CMS edits 06-01-11-FINAL.docx Supplementary Document	2011-06-17
CMS-10095-DENC508-2010 spa_CMS edits 06-01-11-FINAL.docx Supplementary Document	2011-06-17
Crosswalk -- Changes to NOMNC-DENC-SPANISH VERSIONS.docx Supplementary Document	2011-06-17
Justification of Non-material change.docx Justification for No Material/Nonsubstantive Change	2011-06-17
NOMNCtrackchanges508.docx Supplementary Document	2010-07-30
NOMNCforminstructionstrackchanges508.docx Supplementary Document	2010-07-30
DENCtrack changes508.docx Supplementary Document	2010-07-30
DENCforminstructionstrackchanges508.docx Supplementary Document	2010-07-30
Supporting Statement - CMS-10095508 - 2010.doc Supporting Statement A	2011-06-17

IC Document Collections

IC ID	Document Title	Status
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: 201106-0938-017
Status: Historical Active	Previous ICR Reference No: 201011-0938-009
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: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/20/2011
	Date Received in OIRA: 06/20/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2013	10/31/2013	10/31/2013
Responses	100,785	0	100,785
Time Burden (Hours)	45,353	0	45,353
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

Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Detailed Explanation of Non-Coverage (42 CFR 422.626(e)(1)): DENC	CMS-10095-DENC, CMS-10095-DENC-SP	Detailed Explanation of Non-coverage ,   Explicaci?n Detallada de Terminaci?n de la Cobertura
Notice of Medicare Non-Coverage (42 CFR 422.624(b)(1)) : NOMNC (CMS-10095)	CMS-10095-NOMNC, CMS-10095-NOMNC-SP	Notice of Medicare Non-Coverage ,   Notificaci?n de Medicare de Terminaci?n de Cobertura

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ICR Summary 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	100,785	0	0	0	0
Annual Time Burden (Hours)	45,353	45,353	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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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: 06/20/2011

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