Information Collection

Burden Estimates - Appeals

IC 193861 under ICR 201606-0938-004 · OMB 0938-1099.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1099 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10338 Letter to Issuers.pdf	Instruction
CMS-10338 Letter to Issuers in Territories.pdf	Instruction
CMS-10338 Adverse Benefit Determination Model Notice CMS-10338 Adverse Benefit Determination model_notice (2).pdf	Form and Instruction
CMS-10338 Internal Adverse Benefit Determination CMS-10338 Final_Internal Adverse Benefit Determination_model_notice (2).pdf	Form and Instruction
CMS-10338 External Final Decision Model Notice CMS-10338 External_Final_Decision_model_notice (2).pdf	Form and Instruction

IC Title:

Burden Estimates - Appeals

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 147.136

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CMS-10338 Letter to Issuers.pdf	Yes	No	Fillable Fileable
Instruction			CMS-10338 Letter to Issuers in Territories.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10338	Adverse Benefit Determination Model Notice	CMS-10338 Adverse Benefit Determination model_notice (2).pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10338	Internal Adverse Benefit Determination	CMS-10338 Final_Internal Adverse Benefit Determination_model_notice (2).pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10338	External Final Decision Model Notice	CMS-10338 External_Final_Decision_model_notice (2).pdf	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 95,500

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	399,154,868	181,154,868	218,000,000
Annual IC Time Burden (Hours)	1,702,817	772,817	930,000
Annual IC Cost Burden (Dollars)	115,714,242	63,714,242	52,000,000

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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