Information Collection

Burden Estimates - Appeals

IC 193861 under ICR 201911-0938-014 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form CMS-10338 Adverse Benefit Determination Model Notice Burden Estimates - Appeals	Form and Instruction
Form CMS-10338 Internal Adverse Benefit Determination Burden Estimates - Appeals	Form and Instruction
Form CMS-10338 External Final Decision Model Notice Burden Estimates - Appeals	Form and Instruction
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.pdf	Form and Instruction
CMS-10338 Internal Adverse Benefit Determination CMS-10338 - Adverse Benefit Determination model notice.pdf	Form and Instruction
CMS-10338 External Final Decision Model Notice CMS-10338 - Final Internal Adverse Benefit Determination model notice.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.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction		Yes	No	Fillable Fileable
Instruction		Yes	No	Fillable Fileable
Form and Instruction	CMS-10338	Yes	No	Fillable Fileable
Form and Instruction	CMS-10338	Yes	No	Fillable Fileable
Form and Instruction	CMS-10338	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 109,653

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	516,575,283	117,420,415	399,154,868
Annual IC Time Burden (Hours)	1,195,626	-507,191	1,702,817
Annual IC Cost Burden (Dollars)	149,806,832	34,092,590	115,714,242

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.

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