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

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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-10003 NDMC Notice of Denial of Medical Coverage (NDMC), and the Notice of Denial of Payment (NDP) - 42 CFR 422.568 (CMS-10003) Form
CMS10003-NDMC_2008 (3)final.doc Other-Spanish Version NDMC
CMS 10003-NDP_spa2008 (2) (2)final.doc Other-Spanish Version NDP
CMS-10003 NDMC Notice of Denial of Medical Coverage NDMC - 2007.doc Form

Information Collection (IC) Details

IC Title:	Notice 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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10003 NDMC	Notice of Denial of Medical Coverage	NDMC - 2007.doc	Yes	Yes	Paper Only
Other-Spanish Version NDMC			CMS10003-NDMC_2008 (3)final.doc	No	No	Paper Only
Other-Spanish Version NDP			CMS 10003-NDP_spa2008 (2) (2)final.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: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	105,138	105,138
Annual IC Time Burden (Hours)	26,285	26,285
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.