Information Collection

Notice of Provider Non-Coverage (CMS-10123)

IC 8809 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⚠️ Notice: This information collection may be referencing outdated material.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
NOMNCcombinedinstructionsOSORA2014_v508.docx	Instruction
CMS-10123 Notice of Medicare Non-Coverage (NOMNC) [English] NOMNCenglishfinalwordOSORA.docx	Form
CMS-10123 Notificación de Medicare de No-Cobertura (NOMNC) [Spanis NOMNCspanishfinalwordOSORA.docx	Form
NOMNC instructionscrosswalk.xlsx Crosswalk - NOMNC	IC Document

IC Title:

Notice of Provider Non-Coverage (CMS-10123)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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?	Electronic Capability
Instruction			NOMNCcombinedinstructionsOSORA2014_v508.docx	No	Printable Only
Form	CMS-10123	Notice of Medicare Non-Coverage (NOMNC) [English]	NOMNCenglishfinalwordOSORA.docx	No	Fillable Printable
Form	CMS-10123	NotificaciÃ³n de Medicare de No-Cobertura (NOMNC) [Spanish]	NOMNCspanishfinalwordOSORA.docx	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 24,915

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	5,314,194	5,314,194
Annual IC Time Burden (Hours)	885,699	885,699
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk - NOMNC	NOMNC instructionscrosswalk.xlsx	09/11/2014

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