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View ICR - OIRA Conclusion

OMB Control No: 0938-0953	ICR Reference No: 201711-0938-006
Status: Historical Active	Previous ICR Reference No: 201409-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Notice of Provider Non-Coverage (CMS-10123) and Detailed Explanation of Non-Coverage (CMS-10124)
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 with change	Conclusion Date: 05/14/2018
	Date Received in OIRA: 11/27/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2021	36 Months From Approved	05/31/2018
Responses	6,076,944	0	5,339,849
Time Burden (Hours)	1,105,925	0	927,931
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	6,076,944	5,339,849	737,095
Annual Time Burden (Hours)	1,105,925	927,931	177,994
Annual Cost Burden (Dollars)	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 have adjusted our burden based on more consistent NOMNC delivery as well as more accurate reporting of the number of fast appeals requested by beneficiaries and enrollees. Overall, our estimate has been adjusted by +4,941 respondents, +737,095 responses, and +177,944 hours. Our per response estimates are unchanged. See section 15 of this Supporting Statement for details.

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? Uncollected

Agency Contact: Mitch Bryman 410 786-5258 Mitch.Bryman@cms.hhs.gov

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