Medical Necessity Disclosure under MHPAEA (Processed In-House: Paper) : CMS-10307

Medical Necessity Disclosure under MHPAEA and Claims Denial Disclosure under MHPAEA

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1080 can be found here:

Documents and Forms

Document Name Document Type

no available documents/forms check other ICs listed under this ICR

Information Collection (IC) Details

IC Title:	Medical Necessity Disclosure under MHPAEA (Processed In-House: Paper) : CMS-10307	Agency IC Tracking Number:

Is this a Common Form?		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 146.136(d)(1)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20,300	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	620	620
Annual IC Time Burden (Hours)	53	53
Annual IC Cost Burden (Dollars)	397	397

Documents for IC

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