Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146 and 10146SP)

Notice of Denial of Medicare Prescription Drug Coverage

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0976 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10146 Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146 and 10146SP) Form
Denial_Notice_Instructions_2013_Cleanv508(v1).pdf Instruction
CMS-10146 NOTICE OF DENIAL OF MEDICARE PRESCRIPTION DRUG COVERAGE Denial Notice_2013_Cleanv508(v1).pdf Form
Crosswalk- Denial Notice 2013(v2).doc Crosswalk- Denial Notice 2013(v2) IC Document

Information Collection (IC) Details

IC Title:	Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146 and 10146SP)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.568(c) 42 CFR 423.568(d) 42 CFR 423.580 42 CFR 423.582

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10146	NOTICE OF DENIAL OF MEDICARE PRESCRIPTION DRUG COVERAGE	Denial Notice_2013_Cleanv508(v1).pdf		Yes	No	Printable Only
Instruction			Denial_Notice_Instructions_2013_Cleanv508(v1).pdf		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 596	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,497,929	1,207,585	290,344
Annual IC Time Burden (Hours)	374,527	229,355	145,172
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk- Denial Notice 2013(v2)	Crosswalk- Denial Notice 2013(v2).doc	07/25/2013

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.