Information Collection

Notice of Denial of Medical Coverage (or Payment)

IC 8626 under ICR 201604-0938-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Integrated-Denial-Notice-Instructions-CMS-10003_02_2016.pdf	Instruction
CMS-10003 Notice of Denial of Medical Coverage Integrated Denial Notice_CMS_10003_02_2016.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_CMS_10003_02_2016.pdf Crosswalk	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
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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 730

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	7,050,602	90,192	6,960,410
Annual IC Time Burden (Hours)	1,174,630	15,026	1,159,604
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.