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

Information Collection (IC) Details

View Information Collection (IC)

Detailed Explanation of Non-Coverage (CMS-10124)
 
No Modified
 
Required to Obtain or Retain Benefits
 
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 DENC combinednstructionsOSORA2017_v508 (rev 001 by OSORA PRA).pdf No   Fillable Printable
Form CMS-10124 Detailed Explanation of Non-coverage (DENC) [English] DENC English final2017v508 (rev 05-02-2018 by OSORA PRA).pdf No   Fillable Printable
Form CMS-10124 Explicación Detallada No-Cobertura (DENC) [Spanish] DENC Spanishfinalword (rev 05-02-2018 by OSORA PRA).docx No   Fillable Printable

Health Health Care Services

 

28,126 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 85,939 0 0 60,284 0 25,655
Annual IC Time Burden (Hours) 107,424 0 0 65,192 0 42,232
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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