"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)

⚠️ Notice: This information collection may be referencing outdated material.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
CMS-10095 Form Instructions DENC2007fix.doc Other-Instruction CMS-10095 updated
DENCInstructions.pdf Other-Instruction : Original
CMS-10095-DENC_Spa2008 (4) (3)final.doc Other-Spanish Version

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	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Instruction CMS-10095 updated	CMS-10095 Form Instructions DENC2007fix.doc	Yes	Yes	Paper Only
Other-Instruction : Original	DENCInstructions.pdf	Yes	Yes	Paper Only
Other-Spanish Version	CMS-10095-DENC_Spa2008 (4) (3)final.doc	No	No	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: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	38,046	38,046
Annual IC Time Burden (Hours)	9,512	9,512
Annual IC Cost Burden (Dollars)	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.