Information Collection

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

IC 194302 under ICR 201902-1210-006 · OMB 1210-0144.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0144 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Model Notice of Adverse Benefit Determination.doc http;//www.dol.gov/ebsa/IABDModelNotice2.doc	Other-Model
Model Notice of Final Adverse Benefit Determination.doc www.dol.gov/ebsa/IABDModelNotice1.doc	Other-Model
Model Notice of Final External Review Decision.doc www.dol.gov/ebsa/IABDModelNotice3.doc	Other-Model

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	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

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 38,662

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	38,662	6,701	31,961
Annual IC Time Burden (Hours)	2,095	363	1,732
Annual IC Cost Burden (Dollars)	72,386	32,368	40,018

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.