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.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0829 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10003 of Denial of Medical Coverage (NDMC), and the Notice of Denial of Payment (NDP) - 42 CFR 422.568 (CMS-10003)	Form
CMS-10003 Form Instructions NDMC2006.doc	Instruction
CMS-10003 Form Instructions NDP2006.doc	Instruction
CMS-10003 NOTICE OF DENIAL OF MEDICAL COVERAGE CMS-10003 NDMC-2007.pdf	Form
CMS-10003 NDP NOTICE OF DENIAL OF PAYMENT CMS-10003 NDP-2007.pdf	Form

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

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-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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 454

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	105,138	33,938	71,200
Annual IC Time Burden (Hours)	26,285	19,165	7,120
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.