Information Collection

"Detailed Explanation of Non-Coverage and Notice of Medicare Non-Coverage" and Supporting Regulations in 42 CFR 422.626(e)(1) and 42 CFR 422.624(b)(1)

IC 8750 under ICR 200703-0938-013 · OMB 0938-0910.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0910 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10095 DENC "Detailed Explanation of Non-Coverage and Notice of Medicare Non-Coverage" and Supporting Regulations in 42 CFR 422.626(e)(1) and 42 CFR 422.624(b)(1) Form
CMS-10095 Form Instructions DENC2006.doc Instruction
CMS-10095 Form Insrtuctions NOMNC2006.doc Instruction
CMS-10095 DENC Detailed Explanation of Non-Coverage CMS-10095 DENC-2006.doc Form
CMS-10095 NOMNC Notice of Medicare Non-Coverage CMS-10095 Form Insrtuctions NOMNC2006.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	"Detailed Explanation of Non-Coverage and Notice of Medicare Non-Coverage" and Supporting Regulations in 42 CFR 422.626(e)(1) and 42 CFR 422.624(b)(1)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.624(b)(1) 42 CFR 422.626(e)(1)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10095 DENC	Detailed Explanation of Non-Coverage	CMS-10095 DENC-2006.doc	Yes	Yes	Paper Only
Instruction			CMS-10095 Form Instructions DENC2006.doc	Yes	Yes	Paper Only
Form	CMS-10095 NOMNC	Notice of Medicare Non-Coverage	CMS-10095 Form Insrtuctions NOMNC2006.doc	Yes	Yes	Paper Only
Instruction			CMS-10095 Form Insrtuctions NOMNC2006.doc	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 454	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 Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	9,512	-38,046	-564,442	612,000
Annual IC Time Burden (Hours)	14,268	-9,512	-44,220	68,000
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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