OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

of Denial of Medical Coverage (NDMC), and the Notice of Denial of Payment (NDP) - 42 CFR 422.568 (CMS-10003)

IC 8626 under ICR 200704-0938-008 · OMB 0938-0829.

Documents and Forms
Document Name
Document Type
Form
Instruction
Instruction
Form
Form
Information Collection (IC) Details

View Information Collection (IC)

of Denial of Medical Coverage (NDMC), and the Notice of Denial of Payment (NDP) - 42 CFR 422.568 (CMS-10003)
 
No Modified
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10003 NOTICE OF DENIAL OF MEDICAL COVERAGE CMS-10003 NDMC-2007.pdf Yes Yes Paper Only
Form CMS-10003 NDP NOTICE OF DENIAL OF PAYMENT CMS-10003 NDP-2007.pdf Yes Yes Paper Only
Instruction CMS-10003 Form Instructions NDMC2006.doc Yes Yes Paper Only
Instruction CMS-10003 Form Instructions NDP2006.doc Yes Yes Paper Only

Health Health Care Services

 

454 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 105,138 0 0 33,938 0 71,200
Annual IC Time Burden (Hours) 26,285 0 0 19,165 0 7,120
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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