Information Collection

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

IC 8750 under ICR 201008-0938-004 · OMB 0938-0910.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0910 can be found here:

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.