Information Collection

Medicare+Choice Beneficiary Appeal Notices, "Notice of Denial of Medical Services", "Notice of Denial of Request for Payment" and Supporting Regulations in 42 CFR 422.568

IC 8625 under ICR 200103-0938-007 · OMB 0938-0829.

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Information Collection (IC) Details

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IC Title:	Medicare+Choice Beneficiary Appeal Notices, "Notice of Denial of Medical Services", "Notice of Denial of Request for Payment" and Supporting Regulations in 42 CFR 422.568	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-10003				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 29,892	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	29,892	29,892
Annual IC Time Burden (Hours)	2,994	2,994
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded

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