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

MEDICAL NECESSITY DISCLOSURE UNDER MHPAEA AND CLAIMS DENIAL DISCLOSURE UNDER MHPAEA

OMB: 0938-1080

IC ID: 191600

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Claims Denial Disclosure under MHPAEA [Processed By Issuer or Third Party Service] [Electronic]
 
No Modified
 
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

 

78,126 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 329,920 329,920 0 0 0 0
Annual IC Time Burden (Hours) 0 0 0 0 0 0
Annual IC Cost Burden (Dollars) 738,195 738,195 0 0 0 0

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