Notice of Provider Non-Coverage (CMS-10123)

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

OMB: 0938-0953

IC ID: 8809

Documents and Forms
Document Name
Document Type
Instruction
Form
Form
IC Document
Information Collection (IC) Details

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Notice of Provider Non-Coverage (CMS-10123)
 
No Modified
 
Mandatory
 
42 CFR 405.1200 42 CFR 405.1202

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted 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 Notificación de Medicare de No-Cobertura (NOMNC) [Spanish] NOMNCspanishfinalwordOSORA.docx No   Fillable Printable

Health Health Care Services

 

24,915 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   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 5,314,194 0 0 0 0 5,314,194
Annual IC Time Burden (Hours) 885,699 0 0 0 0 885,699
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.
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