Claims Denial Disclosure under MHPAEA [Processed By Issuer or Third Party Service] [Electronic]

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⚠️ Notice: This information collection may be referencing outdated material.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:	Claims Denial Disclosure under MHPAEA [Processed By Issuer or Third Party Service] [Electronic]	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 146.136(d)(2)

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: 78,126	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	329,920	329,920
Annual IC Time Burden (Hours)	0	0
Annual IC Cost Burden (Dollars)	738,195	738,195

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.