Information Collection

Burden Estimates - Appeals

IC 193861 under ICR 202512-0938-019 · OMB 0938-1099.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10338- Model Notice of Final Internal Adverse Benefit Determination.pdf	Other-Model - Notice of Internal Adv
CMS-10338 - Model Notice of Adverse Benefit Determination.pdf	Other-Model Notice of Adverse Benefi
CMS-10338 - Model Notice of Final External Review Decision.pdf	Other-Model Notice of Final External

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 147.136

Information Collection Instruments:

table that charts list of instruments
Document Type	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Model - Notice of Internal Adverse Benefit Determination	Yes	Yes	Fillable Fileable
Other-Model Notice of Adverse Benefit Determination	Yes	Yes	Fillable Fileable
Other-Model Notice of Final External Review Decision	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 91,530

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: 58 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	489,975,255	-26,600,028	516,575,283
Annual IC Time Burden (Hours)	861,470	-334,156	1,195,626
Annual IC Cost Burden (Dollars)	142,092,824	-7,714,008	149,806,832

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.

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