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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.