Information Collection

Reimbursement Denial Letter and Appeal Notification - Providers

IC 233096 under ICR 202201-0920-002 · OMB 0920-0891.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0891 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Reimbursement Denial Letter and Appeal Notification - Providers	Form and Instruction
Reimbursement Denial Letter and Appeal Notification - Pr App TT Reimbursement Appeal Decision Letter.docx	Form and Instruction
Reimbursement Denial Letter and Appeal Notification - Pr App TT Reimbursement Appeal Decision Letter.docx	Form and Instruction

IC Title:

Reimbursement Denial Letter and Appeal Notification - Providers

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 88.23

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	Reimbursement Denial Letter and Appeal Notification - Providers	App TT Reimbursement Appeal Decision Letter.docx		No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: 09-20-0147 Occupational Health Epidemiologic Studies and EEOICPA Program Records and WTC Health Program Records HHS/CDC/NIOSH

FR Citation: 76 FR 34706

Number of Respondents: 600

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	-600	600
Annual IC Time Burden (Hours)	-300	300
Annual IC Cost Burden (Dollars)	-30,000	30,000

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.