Information Collection

Notice of Denial of Medical Coverage (or Payment)

IC 8626 under ICR 201308-0938-010 · 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⚠️ Notice: This information collection may be referencing outdated material.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
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
CMS-10003 Notice of Denial of Medical Coverage (Spanish) SPA_Integrated Denial Notice_clean_03 18 2013v508 - Spa.pdf	Form
Crosswalk_Integrated Denial Notice_03 26 2013.docx Crosswalk_Integrated Denial Notice_03 26 2013	IC Document

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	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
Form	CMS-10003	Notice of Denial of Medical Coverage (Spanish)	SPA_Integrated Denial Notice_clean_03 18 2013v508 - Spa.pdf	Yes	No	Fillable Printable

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: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	6,960,410	6,960,410
Annual IC Time Burden (Hours)	1,159,604	1,159,604
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.