Information Collection

Procedures for Federal External Review and Model Notices

IC 250359 under ICR 202605-1545-006 · OMB 1545-2182.

Documents and Forms

Document Name Document Type
updated-model-notice-of-adverse-benefit-determination_1.17.25_clean.docx www.dol.gov/agencies/ebsa/employers-and-advisers/plan-administration-and-compliance/health-plans Other-Model
updated-model-notice-of-final-external-review-decision_1.17.25_clean (1).docx www.dol.gov/agencies/ebsa/employers-and-advisers/plan-administration-and-compliance/health-plans Other-Model
updated-model-notice-of-final-internal-adverse-benefit-determination_1.17.25_clean.docx www.dol.gov/agencies/ebsa/employers-and-advisers/plan-administration-and-compliance/health-plans Other-Model

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Procedures for Federal External Review and Model Notices	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 54.9815-2719

Information Collection Instruments:

Document Type	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-external-review-decision_1.17.25_clean (1).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

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,294,150	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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	34,872	-41,142	76,014
Annual IC Time Burden (Hours)	4,235	-380	4,615
Annual IC Cost Burden (Dollars)	32,252	1,825	30,427

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.

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