Hospital Notices: IM / DND (CMS-10065/10066)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-100065/10066 Important Message from Medicare	Form and Instruction	Modified	Available
Form CMS-10065/10066 Detailed Notice of Discharge	Form and Instruction	Modified	Available
CMS-10065-10066_SupportingStatement_.docx	Supporting Statement A	Uploaded 2022-08-25	Repair queued
CMS-10065 - Crosswalkv508.pdf	Supplementary Document	Uploaded 2022-08-23	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
237581	Important Message From Medicare	Form and Instruction	Modified	Important Message from Medicare
237581	Important Message From Medicare	Instruction	Modified
179807	Hospital Discharges Detailed Notice of Discharge	Form and Instruction	Modified	Detailed Notice of Discharge
179807	Hospital Discharges Detailed Notice of Discharge	Instruction	Modified

ICR Details

OMB Control No: 0938-1019	ICR Reference No: 202208-0938-019
Status: Historical Active	Previous ICR Reference No: 201912-0938-004
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Hospital Notices: IM / DND (CMS-10065/10066)
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 without change	Conclusion Date: 12/07/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/26/2022
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2025	36 Months From Approved	12/31/2022
Responses	14,087,086	0	17,742,803
Time Burden (Hours)	2,385,108	0	2,990,720
Cost Burden (Dollars)	0	0	0

---

Abstract: For all Medicare beneficiaries, hospitals must deliver valid, written notice of a beneficiary's rights as a hospital inpatient, including discharge appeal rights. The hospital must use a standardized notice, as specified by CMS. This is satisfied by IM delivery. When a QIO notifies a hospital that a beneficiary has requested an expedited discharge, the hospital must deliver a detailed notice to the beneficiary as soon as possible but no later than noon of the day after the QIO's notification. This is satisfied by DND delivery.

---

Authorizing Statute(s): Statute at Large: 18 Stat. 1154
   Statute at Large: 18 Stat. 1866
  

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:
	87 FR 32028	05/26/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 51984	08/24/2022
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Hospital Discharges Detailed Notice of Discharge	CMS-10065/10066	Detailed Notice of Discharge
Important Message From Medicare	CMS-100065/10066	Important Message from Medicare

---

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	14,087,086	17,742,803	0	0	-3,655,717	0
Annual Time Burden (Hours)	2,385,108	2,990,720	0	0	-605,612	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 estimate that hospitals and CAHs will deliver 14,087,086 notices, annually (14,042,374 IMs + 44,712 DNDs). This represents a decrease of 3,655,717 from our last collection. This is likely due to consequences of the pandemic. This resulted in a decrease of -05,612 in burden hours.

---

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? No

---

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: 08/26/2022

---