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⚠️ Notice: This information collection may be referencing outdated material.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 CMMS-10124 Notice of Provider Non-Coverage (CMS-10123) and Detailed Explanation of Non-Coverage (CMS-10124) Form
508_DENC combinednstructions508.pdf Instruction
CMMS-10124 Detailed Explanation of Non-coverage 508_DENCcombined508.pdf Form
CMS-10124 Detailed Explanation of Non-coverage CMS10124spanish.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Notice of Provider Non-Coverage (CMS-10123) and Detailed Explanation of Non-Coverage (CMS-10124)	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMMS-10124	Detailed Explanation of Non-coverage	508_DENCcombined508.pdf	Yes	No	Fillable Fileable
Instruction			508_DENC combinednstructions508.pdf	Yes	No	Fillable Fileable
Form	CMS-10124	Detailed Explanation of Non-coverage	CMS10124spanish.docx	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 25,655	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	25,655	25,655
Annual IC Time Burden (Hours)	42,232	42,232
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.