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

Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408 (CMS-R-131)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408 Form
CMS-R-131 Advanced Beneficiary Notice of Non-coverage ABNEnglish2023v508_CLEAN.pdf Form
CMS-R-131 Advanced Beneficiary Notice of Non-coverage Instructions ABN-Form-Instructions_REDLINED_Post60daycomment(112919)_508.pdf Form and Instruction
CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Spanish Ver (Spanish) ABNEnglish2023_CLEAN_508.pdf Form
ABN Crosswalk (080619).pdf Crosswalk IC Document

Information Collection (IC) Details

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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-R-131	Advanced Beneficiary Notice of Non-coverage	ABNEnglish2023v508_CLEAN.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-R-131	Advanced Beneficiary Notice of Non-coverage Instructions	ABN-Form-Instructions_REDLINED_Post60daycomment(112919)_508.pdf	Yes	No	Printable Only
Form	CMS-R-131	Advanced Beneficiary Notice of Non-coverage (Spanish Version)	(Spanish) ABNEnglish2023_CLEAN_508.pdf	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,589,060	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 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	382,216,385	318,615,085	63,601,300
Annual IC Time Burden (Hours)	44,593,186	37,172,822	7,420,364
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	ABN Crosswalk (080619).pdf	12/18/2019

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