View Information Collection (IC)
View Information Collection (IC)

View Information Collection (IC)

Notice of Denial of Medical Coverage (or Payment)
 
No Modified
 
Mandatory
 
42 CFR 438.404 42 CFR 422.570 42 CFR 422.568 42 CFR 438.402 42 CFR 422.572

Document Type Form No. Form Name Instrument File URL 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

Health Health Care Services

 

970 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 18,232,560 0 0 2,040,748 0 16,191,812
Annual IC Time Burden (Hours) 3,037,544 0 0 339,988 0 2,697,556
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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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