Expedited Review Notices and Supporting Regulations Contained in 42 CFR SEction 405.1200 and 405.1202

Notice of Provider Non-Coverage (CMS-10123) and Detailed Explanation of Non-Coverage (CMS-10124)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0953 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10123 Expedited Review Notices and Supporting Regulations Contained in 42 CFR SEction 405.1200 and 405.1202 Form
508_NOMNCcombinedinstructions508.pdf Instruction
CMS-10123 Notice of Medicare Non-Coverage 508_NOMNCcombined508.pdf Form

Information Collection (IC) Details

IC Title:	Expedited Review Notices and Supporting Regulations Contained in 42 CFR SEction 405.1200 and 405.1202	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 405.1200 42 CFR 405.1202

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10123	Notice of Medicare Non-Coverage	508_NOMNCcombined508.pdf		Yes	No	Fillable Fileable
Instruction			508_NOMNCcombinedinstructions508.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 24,915	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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	5,314,194	2,214,194	3,100,000
Annual IC Time Burden (Hours)	885,699	369,033	516,666
Annual IC Cost Burden (Dollars)	0	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.