Supporting Statement

SUPPORTING STATEMENT
1. CIRCUMSTANCES NECESSITATING COLLECTION OF INFORMATION
Section 2719 of the Public Health Service Act, incorporated into Code section 9815 by section 1563(f) of the Patient
Protection and Affordable Care Act, Public Law 111-148, requires group health plans and issuers of group health
insurance coverage, in connection with internal appeals of claims denials, to provide claimants free of charge with any
evidence relied upon in deciding the appeal that was not relied on in making the initial denial of the claim.

2. USE OF DATA
This is a third party disclosure requirement. Individuals appealing a denial of a claim should be able to respond to any
new evidence the plan or issuer relies on in the appeal, and this disclosure requirement is essential so that the
claimant knows of the new evidence.

3. USE OF IMPROVED INFORMATION TECHNOLOGY TO REDUCE BURDEN
Plans and issuers may satisfy this disclosure requirement by electronic means if they comply with applicable electronic
disclosure requirements.

4. EFFORTS TO IDENTIFY DUPLICATION
The regulations provide that the satisfaction of this obligation by either the plan or the issuer satisfies the obligation for
both parties.

5. METHODS TO MINIMIZE BURDEN ON SMALL BUSINESSES OR OTHER SMALL ENTITIES
The regulations provide that disclosure by either the plan or the issuer will satisfy the obligation for both parties
responsible for the disclsoure. Most small businesses maintaining a group health plan provide benefits through health
insurance coverage. In such a case, it is expected that the issuer of the health insurance coverage will satisfy the
disclosure obligation on behalf of both the plan and the issuer.

6. CONSEQUENCES OF LESS FREQUENT COLLECTION ON FEDERAL PROGRAMS OR
POLICY ACTIVITIES
Not applicable -- occasional third-party disclosure requirement.

Form 14029 (Rev. 4-2009) Catalog Number 51944B Page 4

Department of the Treasury–Internal Revenue Service

7. SPECIAL CIRCUMSTANCES REQUIRING DATA COLLECTION TO BE INCONSISTENT
WITH GUIDELINES IN 5 CFR 1320.5(d)(2)
Not applicable.

8. CONSULTATION WITH INDIVIDUALS OUTSIDE OF THE AGENCY ON AVAILABILITY
OF DATA, FREQUENCY OF COLLECTION, CLARITY OF INSTRUCTIONS AND FORMS,
AND DATA ELEMENTS
In response to the Federal Register Notice dated September 3, 2010 (75 FR 54231), we received no comments during
the comment period regarding Reg-125592-10.

9. EXPLANATION OF DECISION TO PROVIDE ANY PAYMENT OR GIFT TO RESPONDENTS
Not applicable.

10. ASSURANCE OF CONFIDENTIALITY OF RESPONSES
Generally, tax returns and tax return information are confidential as required by 26 USC 6103.

11. JUSTIFICATION OF SENSITIVE QUESTIONS
Not applicable.

12. ESTIMATED BURDEN OF INFORMATION COLLECTION
The Departments estimate that approximately 93 percent of large benefit and all small benefit plans administer claims
use a third-party provider, or roughly 5 percent of covered individuals. In-house administration burdens are accounted
for as hours. Based on the foregoing, total burden hours are estimated at 300 hours (50% to DOL and 50% to IRS).

Form 14029 (Rev. 4-2009) Catalog Number 51944B

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Department of the Treasury–Internal Revenue Service

13. ESTIMATED TOTAL ANNUAL COST BURDEN TO RESPONDENTS
As suggested by OMB, our Federal Register Notice dated September 3, 2010 (75 FR 54231), requested public
comments on estimates of cost burden that are not captured in the estimates of burden hours, i.e., estimates of capital
or start-up costs and costs of operation, maintenance, and purchase of services to provide information. However, we
did not receive any response from taxpayers on this subject. As a result, estimates of these cost burdens are not
available at this time.

14. ESTIMATED ANNUALIZED COST TO THE FEDERAL GOVERNMENT
Not applicable -- third party disclosure.

15. REASONS FOR CHANGE IN BURDEN
There is no change in the burden hours previously approved by OMB. This collection is being submitted for renewal.

16. PLANS FOR TABULATION, STATISTICAL ANALYSIS AND PUBLICATION
Not applicable.

17. REASONS WHY DISPLAYING THE OMB EXPIRATION DATE IS INAPPROPRIATE
We believe that displaying the OMB expiration date is inappropriate because it could cause confusion by leading
taxpayers to believe that the regulations sunset as of the expiration date. Taxpayers are not likely to be aware that the
Service inteneds to request renewal of the OMB approval and obtain a new expiration date before the old one expires.

18. EXCEPTIONS TO THE CERTIFICATION STATEMENT ON OMB PRA SUBMISSION FORM
Not applicable.

19. REASON FOR EMERGENCY SUBMISSION

Form 14029 (Rev. 4-2009) Catalog Number 51944B

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Department of the Treasury–Internal Revenue Service