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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10123 Notificación de Medicare de No-Cobertura (NOMNC) [Spanish]	Form	Modified	Available
Form CMS-10123 Notice of Medicare Non-Coverage (NOMNC) [English]	Form	Modified	Repair queued
Form CMS-10124 Explicación Detallada No-Cobertura (DENC) [Spanish]	Form	Modified	Available
Form CMS-10124 Detailed Explanation of Non-coverage (DENC) [English]	Form	Modified	Available
CMS-10123 and 10124 - SupportingStatement A(2) - Passback CLEAN.docx	Supporting Statement A	Uploaded 2018-05-04	Available
NOMNCpraResponse2.docx	Supplementary Document	Uploaded 2017-11-22	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8809	Notice of Provider Non-Coverage (CMS-10123)	Form	Modified	Notificación de Medicare de No-Cobertura (NOMNC) [Spanish]
8809	Notice of Provider Non-Coverage (CMS-10123)	Form	Modified	Notice of Medicare Non-Coverage (NOMNC) [English]
8809	Notice of Provider Non-Coverage (CMS-10123)	Instruction	Modified
184965	Detailed Explanation of Non-Coverage (CMS-10124)	Form	Modified	Explicación Detallada No-Cobertura (DENC) [Spanish]
184965	Detailed Explanation of Non-Coverage (CMS-10124)	Form	Modified	Detailed Explanation of Non-coverage (DENC) [English]
184965	Detailed Explanation of Non-Coverage (CMS-10124)	Instruction	Modified

ICR Details

OMB Control No: 0938-0953	ICR Reference No: 201711-0938-006
Status: Historical Active	Previous ICR Reference No: 201409-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Notice of Provider Non-Coverage (CMS-10123) and Detailed Explanation of Non-Coverage (CMS-10124)
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 with change	Conclusion Date: 05/14/2018
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/27/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2021	36 Months From Approved	05/31/2018
Responses	6,076,944	0	5,339,849
Time Burden (Hours)	1,105,925	0	927,931
Cost Burden (Dollars)	0	0	0

---

Abstract: 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.

---

Authorizing Statute(s): US Code: 42 USC 521 Name of Law: Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA)
   PL: Pub.L. 106 - 554 521 Name of Law: Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA)
   PL: Pub.L. 108 - 173 234 Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003
   Statute at Large: 18 Stat. 1869
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 44416	09/22/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 55612	11/22/2017
Did the Agency receive public comments on this ICR? Yes

---

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 (CMS-10124)	CMS-10124, CMS-10124	Detailed Explanation of Non-coverage (DENC) [English] ,   Explicación Detallada No-Cobertura (DENC) [Spanish]
Notice of Provider Non-Coverage (CMS-10123)	CMS-10123, CMS-10123	Notice of Medicare Non-Coverage (NOMNC) [English] ,   Notificación de Medicare de No-Cobertura (NOMNC) [Spanish]

---

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	6,076,944	5,339,849	0	0	737,095	0
Annual Time Burden (Hours)	1,105,925	927,931	0	0	177,994	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: We have adjusted our burden based on more consistent NOMNC delivery as well as more accurate reporting of the number of fast appeals requested by beneficiaries and enrollees. Overall, our estimate has been adjusted by +4,941 respondents, +737,095 responses, and +177,944 hours. Our per response estimates are unchanged. See section 15 of this Supporting Statement for details.

---

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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

---

Common Form ICR:  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:

(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: 11/27/2017

---