Information Collection

Notice of Denial of Medical Coverage (or Payment)

IC 8626 under ICR 202211-0938-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form CMS-10003 Notice of Denial of Medical Coverage Notice of Denial of Medical Coverage (or Payment)	Form
Instructions CMS-10003_NDMCP_Notice of Denial of Medical Coverage or Pay....pdf	Instruction
Instructions CMS-10003_NDMCP_Notice of Denial of Medical Coverage or Pay....pdf	Instruction
CMS-10003 Notice of Denial of Medical Coverage CMS-10003_NDMCP_Notice of Denial of Medical Coverage or Payment_2020_v508.pdf	Form
CMS-10003 Notice of Denial of Medical Coverage CMS-10003_NDMCP_Notice of Denial of Medical Coverage or Payment_2020_v508.pdf	Form
CMS-10003 - Crosswalkv508.pdf Crosswalk	IC Document
CMS-10003 - Crosswalkv508.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 422.570 42 CFR 422.572 42 CFR 422.568 42 CFR 438.402

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10003				Yes	No	Fillable Printable
Instruction					Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 937

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	16,191,812	6,818,612	9,373,200
Annual IC Time Burden (Hours)	2,697,556	1,135,981	1,561,575
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk		11/04/2022

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

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