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 422.570 42 CFR 438.404 42 CFR 422.572 42 CFR 422.568 42 CFR 438.402

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 CMS-10003_NDMCP_Notice of Denial of Medical Coverage or Payment_2020_v508.pdf Yes No Fillable Printable
Instruction Instructions CMS-10003_NDMCP_Notice of Denial of Medical Coverage or Pay....pdf Yes No Fillable Printable
Form CMS-10003 Notice of Denial of Medical Coverage of Payment - Spanish SPA_Integrated Denial Notice_ Spa_v508.pdf Yes No Fillable Printable

Health Health Care Services

 

937 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 16,191,812 0 0 0 0 16,191,812
Annual IC Time Burden (Hours) 2,697,556 0 0 0 0 2,697,556
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Crosswalk CMS-10003 - Crosswalkv508.pdf 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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