Detailed Explanation of Non-Coverage (CMS-10124)

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

OMB: 0938-0953

IC ID: 184965

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Document Name
Document Type
Instruction
Form
Form
IC Document
Information Collection (IC) Details

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Detailed Explanation of Non-Coverage (CMS-10124)
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 405.1202 42 CFR 405.1200

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction DENC combinednstructionsOSORA2014_V508.docx No   Fillable Printable
Form CMS-10124 Detailed Explanation of Non-coverage (DENC) [English] DENC English finalwordOSORA.docx No   Fillable Printable
Form CMS-10124 Explicación Detallada No-Cobertura (DENC) [Spanish] DENC SpanishfinalwordOSORA.docx No   Fillable Printable

Health Health Care Services

 

25,655 0
   
Individuals or Households
 
   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 25,655 0 0 0 0 25,655
Annual IC Time Burden (Hours) 42,232 0 0 0 0 42,232
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Crosswalk - DENC Instructions DENCinstructionscrosswalk.xlsx 09/12/2014
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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