Notice of Denial of Medical Coverage (or Payment)

Notice of Denial of Medical Coverage (or Payment) (NDMCP)

⚠️ Notice: This information collection may be referencing outdated material.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 Notice of Denial of Medical Coverage (or Payment) Form
Instructions_Integrated Denial Notice_clean_03 26 2013v508.pdf Instruction
CMS-10003 Notice of Denial of Medical Coverage Integrated Denial Notice_clean_03 26 2013v508.pdf Form
Crosswalk_Integrated Denial Notice_03 26 2013.docx Crosswalk_Integrated Denial Notice_03 26 2013 IC Document

Information Collection (IC) Details

IC Title:	Notice of Denial of Medical Coverage (or Payment)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 438.404 42 CFR 422.568 42 CFR 422.572

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10003	Notice of Denial of Medical Coverage	Integrated Denial Notice_clean_03 26 2013v508.pdf		Yes	No	Fillable Printable
Instruction			Instructions_Integrated Denial Notice_clean_03 26 2013v508.pdf		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 655	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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	6,960,410	5,792,042	1,168,368
Annual IC Time Burden (Hours)	1,159,604	964,876	194,728
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk_Integrated Denial Notice_03 26 2013	Crosswalk_Integrated Denial Notice_03 26 2013.docx	04/21/2013

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