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 201008-0938-013 · 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⚠️ Notice: This information collection may be referencing outdated material.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
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.