Information Collection Request

Advance Beneficiary Notice of Non-Coverage (ABN) (CMS-R-131)

ICR 202511-0938-004 · OMB 0938-0566 · Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Vietnamese Version) Form Modified Available
Form CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Korean Version) Form Modified Available
Form CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Chinese Version) Form Modified Available
Form CMS-R-131 Advanced Beneficiary Notice of Non-coverage (Spanish Version) Form Modified Available
Form CMS-R-131 Advanced Beneficiary Notice of Non-coverage Instructions Form and Instruction Modified Available
Form CMS-R-131 Advanced Beneficiary Notice of Non-coverage Form Modified Available
Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408 Form Modified Missing upstream
CMS-R-131 - Supporting Statement A .docx Supporting Statement A Uploaded 2025-11-21 Repair queued
CMS-R-131 - Supporting Statement A .docx Supporting Statement A Uploaded 2025-11-21 Repair queued
CROSSWALK DOCUMENT ABN_.pdf Supplementary Document Uploaded 2025-11-18 Available
CROSSWALK DOCUMENT ABN_.pdf Supplementary Document Uploaded 2025-11-18 Repair queued
CMS Response to 60-day Public Comments - CMS-R-131.docx Supplementary Document Uploaded 2025-11-18 Available
CMS Response to 60-day Public Comments - CMS-R-131.docx Supplementary Document Uploaded 2025-11-18 Repair queued
Quest Diagnostics.pdf Public Comments Uploaded 2025-10-06 Available
American Clinical Laboratory Association.pdf Public Comments Uploaded 2025-10-06 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
8163 Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408 Form ModifiedAdvanced Beneficiary Notice of Non-coverage (Vietnamese Version)
8163 Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408 Form ModifiedAdvanced Beneficiary Notice of Non-coverage (Korean Version)
8163 Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408 Form ModifiedAdvanced Beneficiary Notice of Non-coverage (Chinese Version)
8163 Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408 Form ModifiedAdvanced Beneficiary Notice of Non-coverage (Spanish Version)
8163 Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408 Form and Instruction ModifiedAdvanced Beneficiary Notice of Non-coverage Instructions
8163 Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408 Form ModifiedAdvanced Beneficiary Notice of Non-coverage
8163 Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408 Form Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
03/31/2029 36 Months From Approved 03/31/2026
331,715,277 0 323,947,630
38,701,221 0 37,794,970
0 0 0





Reginfo record details
1
table that charts list of burden
IC Title Form No. Form Name
Advance Beneficiary Notice of Noncoverage (ABN) and Supporting Regulations in 42 CFR 411.404 and 411.408 CMS-R-131, CMS-R-131, CMS-R-131, CMS-R-131, CMS-R-131, CMS-R-131 ,   ,   ,   ,   ,  

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 331,715,277 323,947,630 0 0 7,767,647 0
Annual Time Burden (Hours) 38,701,221 37,794,970 0 0 906,251 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No