Information Collection

Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146)

IC 37928 under ICR 202002-0938-017 · OMB 0938-0976.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0976 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Denial Notice Instructions 2020 60 day v508.pdf	Instruction
CMS-10146 Notice of Denial of Medicare Part D Prescription Drug Co Denial Notice 2020 30 day FINAL.docx	Form

IC Title:

Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.580 42 CFR 423.582 42 CFR 423.568(c) 42 CFR 423.568(d)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Denial Notice Instructions 2020 60 day v508.pdf		No		Printable Only
Form	CMS-10146	Notice of Denial of Medicare Part D Prescription Drug Coverage	Denial Notice 2020 30 day FINAL.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 525

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	2,887,866	985,811	1,902,055
Annual IC Time Burden (Hours)	721,967	246,453	475,514
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.