Patient-Provider Dispute Resolution Process

OMB Control No. 0938-XXXX
Expiration Date: XX/XX/XXXX

APPENDIX 7
Patient-Provider Dispute Resolution Process
Data Elements
The Departments of the Treasury, Labor, and Health and Human Services (HHS)
(collectively, the Departments) have issued the Requirements Related to Surprise Billing;
Part II interim final rule (XX FR XXXXX), which provides protections for the uninsured by
requiring the Secretary of HHS to establish a process (referred to as patient-provider dispute
resolution) under which an uninsured (or self-pay) individual, with respect to an item or
service, who received, from a health care provider or facility a good faith estimate of the
expected charges for furnishing such item or service to such individual and who after being
furnished such item or service by such provider or facility is billed by such provider or
facility for such item or service for charges that are substantially in excess of such estimate,
may seek a determination from a selected dispute resolution (SDR) entity for the charges to
be paid by such individual to such health care provider or health care facility. Note that this
PRA package is for HHS requirements at 45 CFR 149.620.
The table below identifies data elements that an uninsured (or self-pay) individual, provider,
or facility is required to include in the patient-provider dispute resolution process.
RESPONSIBLE
PARTY
Provider or
Facility

DATA
ELEMENT
Copy of the Good Faith
Estimate

Provider or
Facility

Copy of the Billed Charges

Provider or
Facility

Justification for the
Difference Between the
Good Faith Estimate and
the Bill

1

DESCRIPTION
A copy of the notification of expected
charges for a scheduled or requested item
or service, including and items or services
that are reasonably expected to be provided
in conjunction with such scheduled or
requested item or service, provided by a
co-health care provider or co-health care
facility consistent with statutory provisions
in PHS Act section 2799B-6(2).
A copy of the billed charges provided to
the uninsured (or self-pay) individual for
the qualified item or service under dispute.
If available, information to demonstrate
that the difference between the billed
charges and the expected charges reflects
the costs of a medically necessary qualified
item or service and is based on unforeseen
circumstances that could not have
reasonably been anticipated by the
provider or facility when the good faith

estimate was provided.
Provider or
Facility

Contact Information of the
Health Care Provider or
Health Care Facility (if not
included in Good Faith
Estimate)

Uninsured (or
Self-Pay)
Individual

Information on the Item or
Service Under Dispute

Uninsured (or SelfPay) Individual

Copy of the Provider’s or
Facility’s Total Billed
Charges for the Items or
Services

Uninsured (or
Self-Pay)
Individual

Copy of the Good Faith
Estimate

Uninsured (or
Self-Pay)
Individual

Contact Information of the
Parties Involved

Uninsured (or
Self-Pay)
Individual
Uninsured (or SelfPay) Individual

State Where the Item or
Service in Dispute Was
Furnished
Communication Preference

Paperwork Reduction Act Statement
2

Contact information of the health care
provider or health care facility involved,
including name, email address, phone
number, and mailing address, in the event
that it is not included in the good faith
estimate.
Information sufficient to identify the item
or service under dispute, including the data
of service or the date the item was
provided.
A copy of documentation showing the total
billed charges, by each heath care provider
or health care facility, for all primary items
or services that were provided to an
uninsured (or self-pay) individual and all
other items and services furnished in
conjunction with the primary items and
services, regardless of whether such items
or services were included in the good faith
estimate.
A copy of the notification of expected
charges for a scheduled or requested item
or service, including and items or services
that are reasonably expected to be provided
in conjunction with such scheduled or
requested item or service, provided by a
co-health care provider or co-health care
facility consistent with statutory provisions
in PHS Act section 2799B-6(2).
Contact information of the parties
involved, including name, email address,
phone number, and mailing address in the
event that it is not included in the good
faith estimate.
The State where the item or service in
dispute was furnished, in the event that it is
not included in the good faith estimate.
The uninsured (or self-pay) individuals
communication preference, through the
federal IDR portal, or electronic or paper
mail.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid Office of Management and Budget (OMB)
control number. The Departments are seeking OMB approval for the model as part of the
approval for a new OMB control number 0938-XXXX the time required to complete this
information collection is estimated to average of 13.5 hours per respondent, including the time
to review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850.

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