Information Collection

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

IC 37928 under ICR 202409-0938-015 · OMB 0938-0976.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10146 Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146)	Form
CMS 10146 Instructions Clean.docx	Instruction
CMS 10146 Instructions Clean.docx	Instruction
CMS-10146 Notice of Denial of Medicare Part D Prescription Drug Co Clean CMS 10146 Denial Notice English_508.docx	Form
CMS-10146 Notice of Denial of Medicare Part D Prescription Drug Co Clean CMS 10146 Denial Notice English_508.docx	Form
CMS-10146 Notice of Denial of Medicare Part D Prescription Drug Co S CMS 10146 Denial Notice_508_rev.docx	Form
CMS-10146 Notice of Denial of Medicare Part D Prescription Drug Co C CMS 10146 Denial Notice_508.docx	Form
CMS-10146 Notice of Denial of Medicare Part D Prescription Drug Co K CMS 10146 Denial Notice_508.docx	Form
CMS-10146 Notice of Denial of Medicare Part D Prescription Drug Co V CMS 10146 Denial Notice_508.docx	Form
CMS 10146 Denial Notice English Redline.docx Denial Notice Track Change	IC Document
CMS 10146 Denial Notice English Redline.pdf Denial Notice Track Change	IC Document
CMS 10146 Instructions Redline.docx Denial Notice Instruction Track Change	IC Document
CMS 10146 Instructions Redline.pdf Denial Notice Instruction Track Change	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10146	Notice of Denial of Medicare Part D Prescription Drug Coverage	Clean CMS 10146 Denial Notice English_508.docx	Yes	No	Fillable Printable
Instruction			CMS 10146 Instructions Clean.docx	No		Printable Only
Form	CMS-10146	Notice of Denial of Medicare Part D Prescription Drug Coverage - Spanish	S CMS 10146 Denial Notice_508_rev.docx	Yes	No	Fillable Printable
Form	CMS-10146	Notice of Denial of Medicare Part D Prescription Drug Coverage - Chinese	C CMS 10146 Denial Notice_508.docx	Yes	No	Fillable Printable
Form	CMS-10146	Notice of Denial of Medicare Part D Prescription Drug Coverage - Korean	K CMS 10146 Denial Notice_508.docx	Yes	No	Fillable Printable
Form	CMS-10146	Notice of Denial of Medicare Part D Prescription Drug Coverage - Vietnamese	V CMS 10146 Denial Notice_508.docx	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 772

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,962,857	331,129	2,631,728
Annual IC Time Burden (Hours)	740,714	82,782	657,932
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Denial Notice Track Change	CMS 10146 Denial Notice English Redline.pdf	11/13/2024
Denial Notice Instruction Track Change	CMS 10146 Instructions Redline.pdf	11/13/2024

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