Information Collection

Notice of Denial of Medical Coverage (or Payment)

IC 8626 under ICR 201702-0938-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form CMS-10003 Notice of Denial of Medical Coverage (or Payment) Form
CMS-10003 Notice of Denial of Medical Coverage (Spanish) Clean 02-06-17-SPA_Integrated Denial Notice_03 18 2013v508 - Spa.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

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 (Spanish)	Clean 02-06-17-SPA_Integrated Denial Notice_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: 730	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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	7,050,602	7,050,602
Annual IC Time Burden (Hours)	1,174,630	1,174,630
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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