Information Collection

Notice of Provider Non-Coverage (CMS-10123) and Detailed Explanation of Non-Coverage (CMS-10124)

IC 184965 under ICR 200805-0938-009 · OMB 0938-0953.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0953 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Detailed instructions-clean-2-15.doc	Instruction
Generic Noticed Form Instructions-clean-2-15 .doc	Instruction
CMS-10124 Detailed Explanation of Non-coverage Detailed Notice-clean-2-15-08.doc	Form
CMS-10124 Detailed Explanation of Non-Coverage (Redline) Detailed Notice-Redline-2-4-08.doc	Form
CMS-10123 Notice of Medicare Provider Non-Coverage Generic Notice-clean-2-15.doc	Form
CMS-10123 Notice of Medicare Provider Non-Coverage (Redline Generic Notice-Redline-2-4-08.doc	Form
CROSSWALK DOC 020508 .doc CROSSWALK DOC 020508	IC Document

IC Title:

Notice of Provider Non-Coverage (CMS-10123) and Detailed Explanation of Non-Coverage (CMS-10124)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 405.1200 42 CFR 405.1202

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
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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15,637

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	15,637	15,637
Annual IC Time Burden (Hours)	5,472	5,472
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.