Information Collection

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

IC 184965 under ICR 201112-0938-003 · OMB 0938-0953.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.