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

ICR 200712-0938-009

OMB: 0938-0829

Federal Form Document

ICR Details
0938-0829 200712-0938-009
Historical Active 200704-0938-008
HHS/CMS
of Denial of Medical Coverage (NDMC), and the Notice of Denial of Payment (NDP) - 42 CFR 422.568
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 01/15/2008
Retrieve Notice of Action (NOA) 12/20/2007
  Inventory as of this Action Requested Previously Approved
08/31/2010 08/31/2010 08/31/2010
105,138 0 105,138
26,285 0 26,285
0 0 0

Section 1852(g)(1)(B) requies M+C organizations to provide determinations to deny coverage (i.e., medical services or payment) in writing and include a statement in understandable language of the reasons for the denial and a description of the reconsideration and appeals processes. These notices fulfill the statutory requirement.

Statute at Large: 18 Stat. 1852 Name of Statute: null
   US Code: 42 USC 1395w-22 Name of Law: Implementation of Medicare Advantage Program
  
None

Not associated with rulemaking

  72 FR 3852 01/26/2007
72 FR 17169 04/06/2007
No

1
IC Title Form No. Form Name
of Denial of Medical Coverage (NDMC), and the Notice of Denial of Payment (NDP) - 42 CFR 422.568 (CMS-10003) CMS-10003 NDMC Notice of Denial of Medical Coverage

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 105,138 105,138 0 0 0 0
Annual Time Burden (Hours) 26,285 26,285 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Bonnie Harkless 4107865666

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
12/20/2007


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