Interim Procedures for Federal External Review and Model Notices Relating to Internal Claims and Appeals and External Review under the Patient Protection and Affordable Care Act

Affordable Care Act Internal Claims and Appeals and External Review Procedures for Non-Grandfathered Plans

OMB: 1210-0144

IC ID: 194302

Information Collection (IC) Details

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Interim Procedures for Federal External Review and Model Notices Relating to Internal Claims and Appeals and External Review under the Patient Protection and Affordable Care Act
 
No Modified
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Model Model Notice of Adverse Benefit Determination.doc http;//www.dol.gov/ebsa/IABDModelNotice2.doc Yes Yes Fillable Fileable Signable
Other-Model Model Notice of Final Adverse Benefit Determination.doc http://www.dol.gov/ebsa/IABDModelNotice1.doc Yes Yes Fillable Fileable Signable
Other-Model Model Notice of Final External Review Decision.doc http://www.dol.gov/ebsa/IABDModelNotice3.doc Yes Yes Fillable Fileable Signable

Income Security General Retirement and Disability

 

31,961 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  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 31,961 0 0 2,961 0 29,000
Annual IC Time Burden (Hours) 1,732 0 0 232 0 1,500
Annual IC Cost Burden (Dollars) 40,018 0 0 4,018 0 36,000

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