Information Collection

Detailed Explanation of Non-Coverage (CMS-10124)

IC 184965 under ICR 201409-0938-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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
DENC combinednstructionsOSORA2014_V508.docx	Instruction
CMS-10124 Detailed Explanation of Non-coverage (DENC) [English] DENC English finalwordOSORA.docx	Form
CMS-10124 Explicación Detallada No-Cobertura (DENC) [Spanish] DENC SpanishfinalwordOSORA.docx	Form
DENCinstructionscrosswalk.xlsx Crosswalk - DENC Instructions	IC Document

IC Title:

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 405.1202 42 CFR 405.1200

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available 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	ExplicaciÃ³n Detallada No-Cobertura (DENC) [Spanish]	DENC SpanishfinalwordOSORA.docx	No	Fillable Printable

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
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.