Information Collection

Medical Necessity Disclosure under MHPAEA (Processed In-house: Sent w/Claims Denial Disclosure) (Paper)

IC 191600 under ICR 200912-0938-008 · OMB 0938-1080.

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	Medical Necessity Disclosure under MHPAEA (Processed In-house: Sent w/Claims Denial Disclosure) (Paper)	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	575	575
Annual IC Time Burden (Hours)	48	48
Annual IC Cost Burden (Dollars)	368	368

Documents for IC

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