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 ERISA Plans

Documents and Forms

Document Name Document Type
revised-model-notice-of-adverse-benefit-determination.docx www.dol.gov/agencies/ebsa/employers-and-advisers/plan-administration-and-compliance/health-plans Other-Model
revised-model-notice-of-adverse-benefit-determination.docx www.dol.gov/agencies/ebsa/employers-and-advisers/plan-administration-and-compliance/health-plans Other-Model
revised-model-notice-of-final-internal-adverse-benefit-determination.docx www.dol.gov/agencies/ebsa/employers-and-advisers/plan-administration-and-compliance/health-plans Other-Model
revised-model-notice-of-final-internal-adverse-benefit-determination.docx www.dol.gov/agencies/ebsa/employers-and-advisers/plan-administration-and-compliance/health-plans Other-Model
revised-model-notice-of-final-external-review-decision.docx www.dol.gov/agencies/ebsa/employers-and-advisers/plan-administration-and-compliance/health-plans Other-Model
revised-model-notice-of-final-external-review-decision.docx www.dol.gov/agencies/ebsa/employers-and-advisers/plan-administration-and-compliance/health-plans Other-Model

Information Collection (IC) Details

IC Title:	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: 29 CFR 2590

Information Collection Instruments:

Document Type	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Model	revised-model-notice-of-adverse-benefit-determination.docx	https://www.dol.gov/agencies/ebsa/employers-and-advisers/plan-administration-and-compliance/health-plans	Yes	Yes	Fillable Fileable Signable
Other-Model	revised-model-notice-of-final-internal-adverse-benefit-determination.docx	https://www.dol.gov/agencies/ebsa/employers-and-advisers/plan-administration-and-compliance/health-plans	Yes	Yes	Fillable Fileable Signable
Other-Model	revised-model-notice-of-final-external-review-decision.docx	https://www.dol.gov/agencies/ebsa/employers-and-advisers/plan-administration-and-compliance/health-plans	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: 76,014	Number of Respondents for Small Entity: 20,058

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 93 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	76,014	40,266	35,748
Annual IC Time Burden (Hours)	4,615	3,343	1,272
Annual IC Cost Burden (Dollars)	30,427	-32,875	63,302

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.