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

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 NOMNCcombinedinstructionsOSORA2017_v508 (rev 001 by OSORA PRA).pdf No   Printable Only
Form CMS-10123 Notice of Medicare Non-Coverage (NOMNC) [English] NOMNCenglishfinal2017v508 (rev 05-02-2018 by OSORA PRA) (3).pdf No   Fillable Printable
Form CMS-10123 Notificación de Medicare de No-Cobertura (NOMNC) [Spanish] NOMNCspanishfinalword (rev 05-02-2018 by OSORA PRA).docx No   Fillable Printable

Health Health Care Services

 

27,385 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   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 5,991,005 0 0 676,811 0 5,314,194
Annual IC Time Burden (Hours) 998,501 0 0 112,802 0 885,699
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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