Information Collection

Notice of Denial of Medical Coverage (or Payment)

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

Documents and Forms

Documents and forms in this information collection
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 Notice of Denial of Medical Coverage (or Payment)	Form
Form CMS-10003 Notice of Denial of Medical Coverage of Payment - Spanish Notice of Denial of Medical Coverage (or Payment)	Form
Form CMS-10003 Notice of Denial of Medical Coverage of Payment - Chinese Notice of Denial of Medical Coverage (or Payment)	Form
Form CMS-10003 Notice of Denial of Medical Coverage of Payment - Korean Notice of Denial of Medical Coverage (or Payment)	Form
Form CMS-10003 Notice of Denial of Medical Coverage of Payment - Vietnamese 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:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10003	Yes	No	Fillable Printable
Instruction		Yes	No	Fillable Printable
Form	CMS-10003	Yes	No	Fillable Printable
Form	CMS-10003	Yes	No	Fillable Printable
Form	CMS-10003	Yes	No	Fillable Printable
Form	CMS-10003	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
Notice of Denial of Medical Coverage Track Change		11/13/2024
Form Instructions for the Notice of Denial of Medical Coverage (or Payment) Track Change		11/13/2024

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

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