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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 194302 under ICR 202503-1210-004 · OMB 1210-0144.

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

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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 Modified
 
Mandatory
 
29 CFR 2590

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Model updated-model-notice-of-adverse-benefit-determination_1.17.25_clean.docx https://www.dol.gov/agencies/ebsa/employers-and-advisers/plan-administration-and-compliance/health-plans Yes Yes Fillable Fileable Signable
Other-Model updated-model-notice-of-final-internal-adverse-benefit-determination_1.17.25_clean.docx https://www.dol.gov/agencies/ebsa/employers-and-advisers/plan-administration-and-compliance/health-plans Yes Yes Fillable Fileable Signable
Other-Model updated-model-notice-of-final-external-review-decision_1.17.25_clean.docx https://www.dol.gov/agencies/ebsa/employers-and-advisers/plan-administration-and-compliance/health-plans Yes Yes Fillable Fileable Signable

Income Security General Retirement and Disability

 

1,294,150 1,229,443
   
Private Sector Not-for-profit institutions
 
   0 %

  Approved 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 34,872 0 0 -41,142 0 76,014
Annual IC Time Burden (Hours) 4,235 0 0 -380 0 4,615
Annual IC Cost Burden (Dollars) 32,252 0 0 1,825 0 30,427

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