Affordable Care Act Internal Claims and Appeals and External Review Procedures for ERISA Plans

ICR 202110-1210-001

OMB: 1210-0144

Federal Form Document

Forms and Documents
Document
Name
Status
Supporting Statement A
2021-09-30
Supplementary Document
2021-09-29
ICR Details
1210-0144 202110-1210-001
Active 201902-1210-006
DOL/EBSA
Affordable Care Act Internal Claims and Appeals and External Review Procedures for ERISA Plans
Revision of a currently approved collection   No
Regular
Approved without change 10/07/2021
Retrieve Notice of Action (NOA) 10/07/2021
Approved consistent with the understanding that the agency will review and consider all comments received from the rule in addition to those received during the 60 and 30 FRN periods as this package transitions from an emergency to a standard collection
  Inventory as of this Action Requested Previously Approved
04/30/2022 6 Months From Approved 05/31/2022
190,913 0 329,980
1,621 0 2,816
813,839 0 1,381,946

This collection of information request includes the information collection and third party notice and disclosure requirements that a plan must satisfy under final regulations implementing provisions of the Affordable Care Act pertaining to internal claims and appeals, and the external review process. The No Surprise Act extends the balance billing protections related to external reviews to grandfathered plans. The definitions of group health plan and health insurance issuer that are cited in section 110 of the No Surprises Act include both grandfathered and non-grandfathered plans and coverage. Accordingly, the practical effect of section 110 of the No Surprises Act is that grandfathered health plans must provide external review for adverse benefit determinations involving benefits subject to these surprise billing protections. Grandfathered and non-grandfathered plans must provide claimants, free of charge, any new or additional evidence considered, relied upon, or generated by the plan or issuer in connection with the claim, and the requirement to comply either with a State external review process or a Federal review process. The disclosure requirements of the Federal external review process require (1) a preliminary review by plans of requests for external appeals; (2) Independent Review Organizations (IROs) to notify claimants of eligibility and acceptance for external review; (3) the plan or issuer to provide IROs with documentation and other information considered in making adverse benefit determination; (4) the IRO to forward to the plan or issuer any information submitted by the claimant; (5) plans to notify the claimant and IRO if it reverses its decision; (6) the IRO to notify the claimant and plan of the result of the final external appeal; 7) the IRO to maintain records for six years.

PL: Pub.L. 111 - 148 2719 Name of Law: The Patient Protection and Affordable Care Act
   PL: Pub.L. 116 - 260 No Surprises Act Name of Law: Consolidated Appropriations Act, 2021
  
PL: Pub.L. 116 - 260 No Surprises Act Name of Law: Consolidated Appropriations Act, 2021

1210-AC00 Final or interim final rulemaking 86 FR 55980 10/07/2021

No

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 190,913 329,980 -139,067 0 0 0
Annual Time Burden (Hours) 1,621 2,816 -1,195 0 0 0
Annual Cost Burden (Dollars) 813,839 1,381,946 -568,107 0 0 0
No
No
The No Surprise Act extends the balance billing protection related to external reviews to grandfathered plans. Under Section 110 of the No Surprises Act, grandfathered health plans must provide external review for adverse benefit determinations involving benefits subject to these surprise billing protections. Adjustments to the burden estimates result from updated estimates on the number of ERISA-covered plans and policyholders and increases in wage rates and postage rates. These updated data inputs increase the hour burden by 425 hours compared with the prior submission and increase the cost burden by $245,732 compared with the prior submission.

$0
No
    No
    No
Yes
No
No
No
James Butikofer 202 693-8434 [email protected]

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
10/01/2021


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