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 250359 under ICR 202111-1545-011 · OMB 1545-2182.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1545-2182 can be found here:

Documents and Forms

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

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 2590

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.docx	http;//www.dol.gov/ebsa/IABDModelNotice2.doc	Yes	Yes	Fillable Fileable Signable
Other-Model	Model Notice of Final Adverse Benefit Determination.docx	http://www.dol.gov/ebsa/IABDModelNotice1.doc	Yes	Yes	Fillable Fileable Signable
Other-Model	Model Notice of Final External Review Decision.docx	http://www.dol.gov/ebsa/IABDModelNotice3.doc	Yes	Yes	Fillable Fileable Signable

Federal Enterprise Architecture Business Reference Module

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 35,748

Number of Respondents for Small Entity: 31,101

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 93 %

table that charts list of burden
	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	35,748	35,748
Annual IC Time Burden (Hours)	1,272	1,272
Annual IC Cost Burden (Dollars)	63,302	63,302

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.