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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10003 Notice of Denial of Medical Coverage of Payment - Spanish	Form	Modified	Available
Form CMS-10003 Notice of Denial of Medical Coverage	Form	Modified	Available
Form CMS-10003 Notice of Denial of Medical Coverage (or Payment)	Form	Modified	Repair queued
CMS Response to Public Comments - CMS-10003.docx	Supplementary Document	Uploaded 2023-08-07	Repair queued
CMS-10003 - Supporting Statement A_.docx	Supporting Statement A	Uploaded 2023-08-07	Repair queued
CMS-10003 - Crosswalkv508.pdf	Supplementary Document	Uploaded 2023-08-07	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8626	Notice of Denial of Medical Coverage (or Payment)	Form	Modified	Notice of Denial of Medical Coverage of Payment - Spanish
8626	Notice of Denial of Medical Coverage (or Payment)	Form	Modified	Notice of Denial of Medical Coverage
8626	Notice of Denial of Medical Coverage (or Payment)	Form	Modified
8626	Notice of Denial of Medical Coverage (or Payment)	Instruction	Modified

ICR Details

OMB Control No: 0938-0829	ICR Reference No: 202308-0938-002
Status: Historical Active	Previous ICR Reference No: 202303-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Notice of Denial of Medical Coverage (or Payment) (NDMCP) (CMS-10003)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/18/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/08/2023
Terms of Clearance: CMS failed to address the terms of clearance or provide a plan for how it will address the terms of clearance. Prior to the re-submission of the information collection “Notice of Denial of Medical Coverage (or Payment) (NDMCP) (CMS-10003)” (0938-0829), the agency will evaluate the burden, usability, and clarity of the forms and appeals process. This evaluation will be guided by the principles and priorities set forth in the memorandum titled “Improving Access to Public Benefits Programs Through the Paperwork Reduction Act” (April 13, 2022). The assessment will inform and be integrated in the agency’s next submission of this information collection. OMB recommends CMS use "Generic Clearance for Improving Customer Experience: OMB Circular A–11, Section 280 Implementation) (CMS-10710)" (0938-1382) to user test this form.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2024	36 Months From Approved	12/31/2024
Responses	16,191,812	0	16,191,812
Time Burden (Hours)	2,697,556	0	2,697,556
Cost Burden (Dollars)	0	0	0

---

Abstract: Section 1852(g)(1)(B) of the Social Security Act (SSA) requires Medicare health plans to provide enrollees with a written notice in understandable language that explains the plan's reasons for denying a request for a service or payment for a service the enrollee has already received. The written notice must also include a description of the applicable appeals processes. Regulatory authority for this notice is set forth in Subpart M of Part 422 at 42 CFR 422.568, 422.572, 417.600(b), and 417.840. Section 1932 of the Social Security Act (SSA) sets forth requirements for Medicaid managed care plans, including beneficiary protections related to appealing a denial of coverage or payment. The Medicaid managed care appeals regulations are set forth in Subpart F of Part 438 of Title 42 of the CFR. Rules on the content of the written denial notice can be found at 42 CFR 438.404. This notice combines the existing Notice of Denial of Medicare Coverage with the Notice of Denial of Payment and includes optional language to be used in cases where a Medicare health plan enrollee also receives full Medicaid benefits that are being managed by the Medicare health plan.

---

Authorizing Statute(s): US Code: 42 USC 1395w-22 Name of Law: Implementation of Medicare Advantage Program
   US Code: 42 USC 1396u-2 Name of Law: Provisions Relating to Managed Care
   Statute at Large: 19 Stat. 1932 Name of Statute: Social Security Act
   Statute at Large: 18 Stat. 1852 Name of Statute: Social Security Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 19956	04/04/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 51320	08/03/2023
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Notice of Denial of Medical Coverage (or Payment)	CMS-10003, CMS-10003	Notice of Denial of Medical Coverage ,   Notice of Denial of Medical Coverage of Payment - Spanish

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	16,191,812	16,191,812	0	0	0	0
Annual Time Burden (Hours)	2,697,556	2,697,556	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $870

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/08/2023

---