Detailed Explanation of Non-Coverage (CMS-10124)

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⚠️ Notice: This information collection may be referencing outdated material.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
DENC combinednstructionsOSORA2017_v508 (rev 001 by OSORA PRA).pdf Instruction
DENC combinednstructionsOSORA2017_v508 (rev 001 by OSORA PRA).pdf Instruction
CMS-10124 Detailed Explanation of Non-coverage (DENC) [English] DENC English final2017v508 (rev 05-02-2018 by OSORA PRA).pdf Form
CMS-10124 Detailed Explanation of Non-coverage (DENC) [English] DENC English final2017v508 (rev 05-02-2018 by OSORA PRA).pdf Form
CMS-10124 Explicación Detallada No-Cobertura (DENC) [Spanish] DENC Spanishfinalword (rev 05-02-2018 by OSORA PRA).docx Form
CMS-10124 Explicación Detallada No-Cobertura (DENC) [Spanish] DENC Spanishfinalword (rev 05-02-2018 by OSORA PRA).docx Form

Information Collection (IC) Details

IC Title:	Detailed Explanation of Non-Coverage (CMS-10124)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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			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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 27,232	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	151,400	0	65,461	85,939
Annual IC Time Burden (Hours)	189,250	-164,144	245,970	107,424
Annual IC Cost Burden (Dollars)	0	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.