Information Collection

Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146 and 10146SP)

IC 37928 under ICR 200809-0938-010 · OMB 0938-0976.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0976 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10146SP Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146 and 10146SP)	Form
SP-CoverageDenialNotice Instructions Spanish 06-12-08 (2).doc	Instruction
Coverage Denial Notice TRACKED rev 04 30 08.doc	Other-Form Track changes
Coverage Denial Instructions CLEAN 04 30 08.doc	Instruction
Coverage Denial Instructions TRACKED 04 30 08.doc	Instruction
OMB Passback 10 15 08 Coverage Denial Notice TRACKED 10 16 2008.doc	Instruction
CMS-10146SP Aviso de Negaci?n de la Cobertura de Medicare para Recet SP-CoverageDenialNotice Spanish06-12-08 (2).doc	Form
CMS-10146 Notice of Denial of Medicare Prescription Drug Coverage Coverage Denial Notice CLEAN rev 04 30 08.doc	Form

IC Title:

Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146 and 10146SP)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.568(c) 42 CFR 423.568(d)

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-10146SP	Aviso de Negaci?n de la Cobertura de Medicare para Recetas M?d	SP-CoverageDenialNotice Spanish06-12-08 (2).doc	Yes	Yes	Paper Only
Instruction			SP-CoverageDenialNotice Instructions Spanish 06-12-08 (2).doc	Yes	Yes	Paper Only
Form	CMS-10146	Notice of Denial of Medicare Prescription Drug Coverage	Coverage Denial Notice CLEAN rev 04 30 08.doc	Yes	Yes	Paper Only
Other-Form Track changes			Coverage Denial Notice TRACKED rev 04 30 08.doc	Yes	Yes	Paper Only
Instruction			Coverage Denial Instructions CLEAN 04 30 08.doc	Yes	Yes	Paper Only
Instruction			Coverage Denial Instructions TRACKED 04 30 08.doc	Yes	Yes	Paper Only
Instruction			OMB Passback 10 15 08 Coverage Denial Notice TRACKED 10 16 2008.doc	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 758

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	290,344	-765,656	1,056,000
Annual IC Time Burden (Hours)	145,172	-382,828	528,000
Annual IC Cost Burden (Dollars)	0	-53,000	53,000

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.