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

Affordable Care Act Internal Claims and Appeals and External review Disclosures.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

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:

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

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 %

	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

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.