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 Procedures for Non-Grandfathered Plans

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0144 can be found here:

Documents and Forms

Document Name Document Type
Model Notice of Adverse Benefit Determination.doc http;//www.dol.gov/ebsa/IABDModelNotice2.doc Other-Model
Model Notice of Final Adverse Benefit Determination.doc www.dol.gov/ebsa/IABDModelNotice1.doc Other-Model
Model Notice of Final External Review Decision.doc 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: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Model	Model Notice of Adverse Benefit Determination.doc	http;//www.dol.gov/ebsa/IABDModelNotice2.doc	Yes	Yes	Fillable Fileable Signable
Other-Model	Model Notice of Final Adverse Benefit Determination.doc	http://www.dol.gov/ebsa/IABDModelNotice1.doc	Yes	Yes	Fillable Fileable Signable
Other-Model	Model Notice of Final External Review Decision.doc	http://www.dol.gov/ebsa/IABDModelNotice3.doc	Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 31,961	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 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	31,961	2,961	29,000
Annual IC Time Burden (Hours)	1,732	232	1,500
Annual IC Cost Burden (Dollars)	40,018	4,018	36,000

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.