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Federal forms, ICRs, and supporting documents

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.

Documents and Forms
Document Name
Document Type
Other-Model
Other-Model
Other-Model
Information Collection (IC) Details

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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
 
No New
 
Mandatory
 
29 CFR 2590

Document Type Form No. Form Name 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

General Government Taxation Management

 

35,748 31,101
   
Private Sector Businesses or other for-profits
 
   93 %

  Requested 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 35,748 35,748 0 0 0 0
Annual IC Time Burden (Hours) 1,272 1,272 0 0 0 0
Annual IC Cost Burden (Dollars) 63,302 63,302 0 0 0 0

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