Information Collection

CMS-10710.GenIC#10.- Notice Testing: CMS Notice of Denial of Medical Coverage (CMS-10003)

IC 267346 under ICR 202402-0938-008 · OMB 0938-1382.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10003 Notice Testing Guide CMS-10710.GenIC#10.- Notice Testing: CMS Notice of Denial of Medical Coverage (CMS-10003)	Form and Instruction
Form CMS-10003 Notice of Denial of Medical Coverage CMS-10710.GenIC#10.- Notice Testing: CMS Notice of Denial of Medical Coverage (CMS-10003)	Form and Instruction
CMS-10003 Notice Testing Guide CMS-10710.GenIC_#10-CMS-10003_IDN_2024_for_testing_0424.docx	Form and Instruction
CMS-10003 Notice of Denial of Medical Coverage CMS-10710.GenIC_#10-CMS10003_Instrument_0424.docx	Form and Instruction
CMS-10710.GenIC_#10-ICR Template_A11_Section_280_Clearance_CMS10003 (5-1-24).docx CMS-10710.GenIC_#10-ICR Template_A11_Section_280_Clearance_CMS10003 (5-1-24)	IC Document

IC Title:

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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 and Instruction	CMS-10003				Yes	Yes	Fillable Printable
Form and Instruction	CMS-10003				Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 24

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	24	24
Annual IC Time Burden (Hours)	24	24
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10710.GenIC_#10-ICR Template_A11_Section_280_Clearance_CMS10003 (5-1-24)		05/01/2024

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

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