Detailed Explanation of Non-Coverage (CMS-10124)

Fast Appeals Notices: NOMNC/DENC (CMS-10123/10124)

Documents and Forms

Document Name Document Type
DENC_instructions_2024_.docx Instruction
DENC_instructions_2024_.docx Instruction
CMS-10124 Detailed Explanation of Non-coverage (DENC) [English] DENC_2024_.docx Form
CMS-10124 Detailed Explanation of Non-coverage (DENC) [English] DENC_2024_.docx Form
CMS-10124 Explicación Detallada No-Cobertura (DENC) [Spanish] DENC_2024_Spanish_.docx Form
CMS-10124 Explicación Detallada No-Cobertura (DENC) [Spanish] DENC_2024_Spanish_.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_instructions_2024_.docx	No	Fillable Printable
Form	CMS-10124	Detailed Explanation of Non-coverage (DENC) [English]	DENC_2024_.docx	No	Fillable Printable
Form	CMS-10124	Explicación Detallada No-Cobertura (DENC) [Spanish]	DENC_2024_Spanish_.docx	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 26,399	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	Previously Approved
Annual Number of Responses for this IC	369,755	218,355	151,400
Annual IC Time Burden (Hours)	472,305	283,055	189,250
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.