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 Service] [Electronic] Unchanged 329920 0 738195
Claims Denial Disclosure under MHPAEA [Processed By Issuer or Third Party Service] [Paper] Unchanged 109973 0 318647
Claims Denial Disclosure under MHPAEA [Processed In-House] [Electronic] Unchanged 17730 1478 0
Claims Denial Disclosure under MHPAEA [Processed In-House] [Paper] Unchanged 5910 493 0
Disclosure Request Form New 184733 15394 0 Form and Instruction CMS-10307 Disclosure Request Form
Disclosure under MHPAEA [Processed By Issuer in the Individual Market] Modified 304985 25415 0
Medical Necessity Disclosure under MHPAEA [Processed In-House] [Electronic] Unchanged 1595 133 0
Medical Necessity Disclosure under MHPAEA [sent with Claims Denial Disclosure] [Processed In-House] [Electronic] Unchanged 1773 148 0
Medical Necessity Disclosure under MHPAEA [sent with Claims Denial Disclosure] [Processed In-House] [Paper] Unchanged 591 49 0
Medical Necessity Disclosure under MHPAEA [Processed By Issuer or Third Party Service] [Electronic] Unchanged 29688 0 66426
Medical Necessity Disclosure under MHPAEA [Processed By Issuer or Third Party Service] [Paper] Unchanged 48438 0 140348
Medical Necessity Disclosure under MHPAEA [Processed In-House] [Paper] Unchanged 2603 217 0
Medical Necessity Disclosure under MHPAEA [Sent with Claims Denial Disclosure] [Processed By Issuer or Third Party Service] [Electronic] Modified 32992 0 73820
Medical Necessity Disclosure under MHPAEA [Sent with Claims Denial Disclosure] [Processed By Issuer or Third Party Service] [Paper] Modified 10997 0 31865
Total burden requested under this ICR: 1081928 43327 1369301  
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