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⚠️ Notice: This information collection may be referencing outdated material.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
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
CMS-10003-NDMC-SP Aviso de Denegaci?n de Cobertura M?dica CMS-10003-NDMC-508--2010 Spa.docx Form
CMS-10003-NDP-SP Aviso de Denegaci?n de Pago CMS-10003-NDP508-2010 spa.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
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

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	Previously Approved
Annual Number of Responses for this IC	1,168,368	1,168,368
Annual IC Time Burden (Hours)	194,728	194,728
Annual IC Cost Burden (Dollars)	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.