Claims Denial Disclosure under MHPAEA

Medical Necessity Disclosure Under MHPAEA and Claims Denial Disclosure Under MHPAEA (CMS-10307)

OMB: 0938-1080

IC ID: 191600

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Claims Denial Disclosure under MHPAEA
 
No Modified
 
Mandatory
 
45 CFR 146.136(d)(2)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability

Health Health Care Services

 

82,711 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   25 %

  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 669,701 0 0 339,781 0 329,920
Annual IC Time Burden (Hours) 55,809 0 0 55,809 0 0
Annual IC Cost Burden (Dollars) 0 0 0 -738,195 0 738,195

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