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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 201011-0938-013 · OMB 0938-0829.

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Notice of Denial of Medical Coverage (NDMC), and the Notice of Denial of Payment (NDP) - 42 CFR 422.568 (CMS-10003)
 
No Modified
 
Mandatory
 
42 CFR 422.568

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
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
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-SP Aviso de Denegaci?n de Cobertura M?dica CMS-10003-NDMC-508--2010 Spa.docx Yes No Fillable Printable
Form CMS-10003-NDP-SP Aviso de Denegaci?n de Pago CMS-10003-NDP508-2010 spa.doc Yes No Fillable Printable

Health Health Care Services

 

740 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,168,368 0 0 0 0 1,168,368
Annual IC Time Burden (Hours) 194,728 0 0 0 0 194,728
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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
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