Information Collection

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

IC 8163 under ICR 201912-0938-015 · OMB 0938-0566.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-131 Advanced Beneficiary Notice of Non-coverage Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408	Form
Form CMS-R-131 Advanced Beneficiary Notice of Non-coverage Instructions Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408	Form and Instruction
Form CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Spanish Version) 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

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:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-R-131	Yes	No	Fillable Fileable
Form and Instruction	CMS-R-131	Yes	No	Printable Only
Form	CMS-R-131	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: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk		12/18/2019

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

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