Information Collection

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

IC 8626 under ICR 200902-0938-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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 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

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:

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 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 %

table that charts list of burden
	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

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.