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OMB Control No: 0938-0829	ICR Reference No: 201304-0938-006
Status: Historical Active	Previous ICR Reference No: 201106-0938-016
Agency/Subagency: HHS/CMS	Agency Tracking No: 19296
Title: Notice of Denial of Medical Coverage (or Payment) (NDMCP)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/10/2013
	Date Received in OIRA: 04/25/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2016	36 Months From Approved	10/31/2013
Responses	6,960,410	0	1,168,368
Time Burden (Hours)	1,159,604	0	194,728
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
   Statute at Large: 18 Stat. 1852
   US Code: 42 USC 1396u-2 Name of Law: Provisions Relating to Managed Care
   Statute at Large: 19 Stat. 1932

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:
	77 FR 55216	09/07/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 21955	04/12/2013
Did the Agency receive public comments on this ICR? Yes

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

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

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	6,960,410	1,168,368	5,792,042
Annual Time Burden (Hours)	1,159,604	194,728	964,876
Annual Cost Burden (Dollars)	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: The annual hour burden associated with this collection is estimated to be 1,159,604 hours. The annual hour burden in the 2010 submission for this collection was 194,728 hours. As discussed in Supporting Statement section 12, the significant increase in the burden estimates is due to the use of Medicare health plan reported data on organization determinations which was not available when the previous PRA package was submitted for this collection. CMS believes the 2011 plan reported data are the most current and reliable data available for the purpose of developing the burden estimates for CMS-10003. Program changes have been made since the publication of the 60-day FR notice. Those changes can be found in the NDMCP Crosswalk.

Annual Cost to Federal Government: $0

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? 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? Uncollected

Agency Contact: Mitch Bryman 410 786-5258 Mitch.Bryman@cms.hhs.gov

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