Notice of Denial of Medical Coverage (or Payment)

Notice of Denial of Medical Coverage (or Payment) (NDMCP) (CMS-10003)

OMB: 0938-0829

IC ID: 8626

Information Collection (IC) Details

View Information Collection (IC)

Notice of Denial of Medical Coverage (or Payment)
 
No Modified
 
Mandatory
 
42 CFR 438.404 42 CFR 422.568 42 CFR 422.572

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction Integrated-Denial-Notice-Instructions-CMS-10003_02_2016.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
Form CMS-10003 Notice of Denial of Medical Coverage Integrated Denial Notice_CMS_10003_02_2016.pdf Yes No Fillable Printable

Health Health Care Services

 

730 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 7,050,602 0 90,192 0 0 6,960,410
Annual IC Time Burden (Hours) 1,174,630 0 15,026 0 0 1,159,604
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Crosswalk Crosswalk_Integrated Denial Notice_CMS_10003_02_2016.pdf 04/10/2016
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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