View Information Collection (IC)
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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Expedited Review Notices and Supporting Regulations Contained in 42 CFR SEction 405.1200 and 405.1202
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
42 CFR 405.1200
42 CFR 405.1202
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Instruction
Detailed instructions-clean-2-15.doc
Yes
Yes
Paper Only
Form
CMS-10124
Detailed Explanation of Non-coverage
Detailed Notice-clean-2-15-08.doc
Yes
Yes
Paper Only
Form
CMS-10124
Detailed Explanation of Non-Coverage (Redline)
Detailed Notice-Redline-2-4-08.doc
Yes
Yes
Paper Only
Form
CMS-10123
Notice of Medicare Provider Non-Coverage
Generic Notice-clean-2-15.doc
Yes
Yes
Paper Only
Form
CMS-10123
Notice of Medicare Provider Non-Coverage (Redline
Generic Notice-Redline-2-4-08.doc
Yes
Yes
Paper Only
Instruction
Generic Noticed Form Instructions-clean-2-15 .doc
Yes
Yes
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
3,100,000
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
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
3,100,000
0
0
-1,192,400
0
4,292,400
Annual IC Time Burden (Hours)
516,666
0
0
137,266
0
379,400
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
CROSSWALK DOC 020508
CROSSWALK DOC 020508 .doc
05/15/2008
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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