Notice of Provider Non-Coverage (CMS-10123)

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0953 can be found here:

Documents and Forms

Document Name Document Type
NOMNCcombinedinstructionsOSORA2017_v508 (rev 001 by OSORA PRA).pdf Instruction
CMS-10123 Notice of Medicare Non-Coverage (NOMNC) [English] NOMNCenglishfinal2017v508 (rev 05-02-2018 by OSORA PRA) (3).pdf Form
CMS-10123 Notificación de Medicare de No-Cobertura (NOMNC) [Spanis NOMNCspanishfinalword (rev 05-02-2018 by OSORA PRA).docx Form

Information Collection (IC) Details

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:

Document Type	Form No.	Form Name	Instrument File	Available 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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 27,385	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5,991,005	676,811	5,314,194
Annual IC Time Burden (Hours)	998,501	112,802	885,699
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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