Detailed Explanation of Non-Coverage (42 CFR 422.626(e)(1)): DENC

Detailed Explanation of Non-Coverage (42 CFR 422.626(e)(1)), and Notice of Medicare Non-Coverage (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⚠️ Notice: This information collection may be referencing outdated material.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
DENC Form Instructions - 2010508.doc Instruction
CMS-10095-DENC Detailed Explanation of Non-coverage DENC508 - 2010.doc Form
DENCforminstructionstrackchanges508.docx DENCforminstructionstrackchanges508 IC Document
DENCtrack changes508.docx DENCtrack changes508 IC Document

Information Collection (IC) Details

IC Title:	Detailed Explanation of Non-Coverage (42 CFR 422.626(e)(1)): DENC	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	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			DENC Form Instructions - 2010508.doc		Yes	No	Paper Only
Form	CMS-10095-DENC	Detailed Explanation of Non-coverage	DENC508 - 2010.doc		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 740	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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	20,157	10,645	9,512
Annual IC Time Burden (Hours)	25,196	10,928	14,268
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
DENCforminstructionstrackchanges508	DENCforminstructionstrackchanges508.docx	07/30/2010
DENCtrack changes508	DENCtrack changes508.docx	07/30/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.