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⚠️ Notice: This information collection may be referencing outdated material.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
Form CMS-10123 Notice of Provider Non-Coverage (CMS-10123) Form
NOMNCcombinedinstructionsOSORA2017_v508 (rev 001 by OSORA PRA).pdf Instruction
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 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
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 405.1202 42 CFR 405.1200

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: 26,535	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5,720,996	-270,009	5,991,005
Annual IC Time Burden (Hours)	953,499	-45,002	998,501
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.