Medical Necessity Disclosure under MHPAEA [sent with Claims Denial Disclosure] [Processed In-House] [Electronic]

MEDICAL NECESSITY DISCLOSURE UNDER MHPAEA AND CLAIMS DENIAL DISCLOSURE UNDER MHPAEA (CMS-10307)

⚠️ Notice: This information collection may be referencing outdated material.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:	Medical Necessity Disclosure under MHPAEA [sent with Claims Denial Disclosure] [Processed In-House] [Electronic]	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 146.136(d)(1)

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: 4,199	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,773	1,773
Annual IC Time Burden (Hours)	148	148
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.