Expedited Review Notices and Supporting Regulations Contained in 42 CFR SEction 405.1200 and 405.1202

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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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	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: 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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,100,000	-1,192,400	4,292,400
Annual IC Time Burden (Hours)	516,666	137,266	379,400
Annual IC Cost Burden (Dollars)	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.