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))

OMB: 0938-0910

IC ID: 8750

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Instruction
Form
Form
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IC Document
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Detailed Explanation of Non-Coverage (42 CFR 422.626(e)(1)): DENC
 
No Modified
 
Mandatory
 
42 CFR 422.624(b)(1) 42 CFR 422.626(e)(1)

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
Form CMS-10095-DENC-SP Explicaci?n Detallada de Terminaci?n de la Cobertura CMS-10095-DENC508-2010 spa.doc Yes No Fillable Printable

Health Health Care Services

 

740 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 20,157 0 0 0 0 20,157
Annual IC Time Burden (Hours) 25,196 0 0 0 0 25,196
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.
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