Information Collection

Notice of Denial of Medical Coverage (or Payment)

IC 8626 under ICR 202409-0938-016 · OMB 0938-0829.

Documents and Forms

Document Name Document Type
Form CMS-10003 Notice of Denial of Medical Coverage (or Payment) Form
Instructions_NDMCP_clean_508.docx Instruction
Instructions_NDMCP_clean_508.docx Instruction
CMS-10003 Notice of Denial of Medical Coverage CMS-10003 - clean_508.docx Form
CMS-10003 Notice of Denial of Medical Coverage CMS-10003 - clean_508.docx Form
CMS-10003 Notice of Denial of Medical Coverage of Payment - Spanis Spanish_CMS-10003.docx Form
CMS-10003 Notice of Denial of Medical Coverage of Payment - Spanis Spanish_CMS-10003.docx Form
CMS-10003 Notice of Denial of Medical Coverage of Payment - Chines C_CMS-10003_508.docx Form
CMS-10003 Notice of Denial of Medical Coverage of Payment - Korean K CMS-10003_508.docx Form
CMS-10003 Notice of Denial of Medical Coverage of Payment - Vietna V CMS-10003_508.docx Form
CMS-10003 - redline.docx Notice of Denial of Medical Coverage Track Change IC Document
CMS-10003 - redline.pdf Notice of Denial of Medical Coverage Track Change IC Document
Instructions_NDMCP_redline.docx Form Instructions for the Notice of Denial of Medical Coverage (or Payment) Track Change IC Document
Instructions_NDMCP_redline.pdf Form Instructions for the Notice of Denial of Medical Coverage (or Payment) Track Change IC Document

Information Collection (IC) Details

View Information Collection (IC)

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 422.568 42 CFR 438.402 42 CFR 422.572

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 - clean_508.docx	Yes	No	Fillable Printable
Instruction			Instructions_NDMCP_clean_508.docx	Yes	No	Fillable Printable
Form	CMS-10003	Notice of Denial of Medical Coverage of Payment - Spanish	Spanish_CMS-10003.docx	Yes	No	Fillable Printable
Form	CMS-10003	Notice of Denial of Medical Coverage of Payment - Chinese	C_CMS-10003_508.docx	Yes	No	Fillable Printable
Form	CMS-10003	Notice of Denial of Medical Coverage of Payment - Korean	K CMS-10003_508.docx	Yes	No	Fillable Printable
Form	CMS-10003	Notice of Denial of Medical Coverage of Payment - Vietnamese	V CMS-10003_508.docx	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 970	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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	18,232,560	2,040,748	16,191,812
Annual IC Time Burden (Hours)	3,037,544	339,988	2,697,556
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Notice of Denial of Medical Coverage Track Change	CMS-10003 - redline.pdf	11/13/2024
Form Instructions for the Notice of Denial of Medical Coverage (or Payment) Track Change	Instructions_NDMCP_redline.pdf	11/13/2024

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