Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Claims Denial Disclosure under MHPAEA (Processed By Issuer or Third Party Services) (Electronic) New 316725 0 712631
Claims Denial Disclosure under MHPAEA (Processed By Issuer or Third Party Services) (Paper) New 105575 0 305112
Claims Denial Disclosure under MHPAEA (Processed In-house)(Electronic)) New 17025 1425 0
Claims Denial Disclosure under MHPAEA (Processed In-house)(Paper) New 5675 475 3632
Medical Necessity Disclosure under MHPAEA (Processed By Issuer or Third Party Services) (Electronic) New 7334 0 16795
Medical Necessity Disclosure under MHPAEA (Processed By Issuer or Third Party Services) (Paper) New 11966 0 34582
Medical Necessity Disclosure under MHPAEA (Processed In-House: Paper) : CMS-10307 New 620 53 397
Medical Necessity Disclosure under MHPAEA (Processed In-House:Electronic) New 380 33 0
Medical Necessity Disclosure under MHPAEA (Processed In-house: Sent w/Claims Denial Disclosure) (Paper) New 575 48 368
Medical Necessity Disclosure under MHPAEA (Processed In-house: sent w/Claims Denial Disclosure)(Electronic)) New 1725 143 0
Medical Necessity Disclosure under MHPAEA(Processed By Issuer or Third Party Services) Sent w Claims Denial Dis) (Electronic) New 31500 0 70875
Medical Necessity Disclosure under MHPAEA(Processed By Issuer or Third Party Services) Sent w Claims Denial Dis) (Paper) New 10500 0 30345
Total burden requested under this ICR: 509600 2177 1174737  
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