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)

OMB: 0938-0566

IC ID: 8163

Information Collection (IC) Details

View Information Collection (IC)

Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408
 
No Modified
 
Mandatory
 
42 CFR 411.404(b) and (c) 42 CFR 411.408(d)(2) and (f)

Document Type Form No. Form Name Instrument File URL 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

Health Health Care Services

 

1,589,060 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   0 %

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

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