Notice of Denial of Medical Coverage (or Payment)

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

⚠️ Notice: This information collection may be referencing outdated material.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
Form CMS-10003 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 Notice of Denial of Medical Coverage of Payment - Spanis SPA_Integrated Denial Notice_ Spa_v508.pdf Form
CMS-10003 Notice of Denial of Medical Coverage of Payment - Spanis SPA_Integrated Denial Notice_ Spa_v508.pdf Form
CMS-10003 - Crosswalkv508.pdf Crosswalk IC Document
CMS-10003 - Crosswalkv508.pdf Crosswalk IC Document

Information Collection (IC) Details

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

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	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

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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	16,191,812	16,191,812
Annual IC Time Burden (Hours)	2,697,556	2,697,556
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.