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⚠️ Notice: This information collection may be referencing outdated material.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
NDMC Form Instructions - 2010 - 508.doc Instruction
NDP Form Instructions - 2010 - 508.doc Instruction
CMS 10003-NDMC Notice of Denial of Medical Coverage NDMC - 2010 - 508--07-21-10.docx Form
CMS 10003-NDP Notice of Denial of Payment NDP - 2010 - 508--07-21-10.doc Form
NDPforminstructionstrackchanges508.docx NDPforminstructionstrackchanges508 IC Document
NDMCforminstructionstrackchanges508.docx NDMCforminstructionstrackchanges508 IC Document
NDP - 2010 - 508--07-21-10-Track Changes.doc NDP - 2010 - 508--07-21-10-Track Changes IC Document
NDMC - 2010 - 508--07-21-10-Track Changes.docx NDMC - 2010 - 508--07-21-10-Track Changes IC Document

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: 42 CFR 422.568

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			NDP Form Instructions - 2010 - 508.doc	Yes	No	Printable Only
Form	CMS 10003-NDP	Notice of Denial of Payment	NDP - 2010 - 508--07-21-10.doc	Yes	No	Fillable Printable
Form	CMS 10003-NDMC	Notice of Denial of Medical Coverage	NDMC - 2010 - 508--07-21-10.docx	Yes	No	Fillable Printable
Instruction			NDMC Form Instructions - 2010 - 508.doc	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 740	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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,168,368	1,063,230	105,138
Annual IC Time Burden (Hours)	194,728	168,443	26,285
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
NDPforminstructionstrackchanges508	NDPforminstructionstrackchanges508.docx	07/16/2010
NDMCforminstructionstrackchanges508	NDMCforminstructionstrackchanges508.docx	07/16/2010
NDP - 2010 - 508--07-21-10-Track Changes	NDP - 2010 - 508--07-21-10-Track Changes.doc	07/23/2010
NDMC - 2010 - 508--07-21-10-Track Changes	NDMC - 2010 - 508--07-21-10-Track Changes.docx	07/23/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.