Claims Denial Disclosure under MHPAEA (Processed By Issuer or Third Party Services) (Electronic)

Medical Necessity Disclosure under MHPAEA and Claims Denial Disclosure under MHPAEA

OMB: 0938-1080

IC ID: 191609

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Claims Denial Disclosure under MHPAEA (Processed By Issuer or Third Party Services) (Electronic)
 
No New
 
Mandatory
 
45 CFR 146.136(d)(2)

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

Health Health Care Services

 

20,300 0
   
State, Local, and Tribal Governments
 
   100 %

  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 316,725 316,725 0 0 0 0
Annual IC Time Burden (Hours) 0 0 0 0 0 0
Annual IC Cost Burden (Dollars) 712,631 712,631 0 0 0 0

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

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