Patient-Provider Dispute Resolution Process

OMB Control Number: 0938-XXXX
Expiration Date: xx/xx/xxxx
APPENDIX 9
Standard Notice: Selected Dispute Resolution (SDR) Entity Notification to Health Care Providers
and Uninsured (or self-pay) Individuals
(For use by SDR Entities beginning January 1, 2022)
Instructions
Under Section 2799B-7 of the Public Health Service Act, the U.S. Department of Health & Human
Services (HHS) is required to establish a patient-provider dispute resolution process where an SDR
entity can resolve a payment dispute between individuals who are not enrolled in a plan or coverage or a
Federal health care program (uninsured individuals), or individuals who are enrolled but not seeking to
file a claim with their plan or coverage (self-pay individuals) by determining the amount such individual
is to pay to such health care provider. Under federal criteria, once HHS determines that an individual is
eligible to dispute billed charges, HHS must select an SDR entity for the dispute resolution.
Once HHS assigns an SDR entity to a dispute, this notice must be used by the SDR entity to inform both
parties (the uninsured individual and the health care provider or health care facility) of the selection.
Additionally, the SDR entity must request that the health care provider submit specific information
within 10 business days of receipt of this notice so the SDR entity can use the data to make a
determination on the dispute.
HHS has developed this standard notice so that providers or facilities and uninsured individuals are
informed of the SDR entity selection. To use this standard notice, the SDR entity, must fill in the blanks
with the appropriate information. HHS considers use of the standard notice to be good faith compliance.
NOTE: The information provided in these instructions is intended only to be a general informal
summary of technical legal standards. It is not intended to take the place of the statutes, regulations, or
formal policy guidance upon which it is based. Readers should refer to the applicable statutes,
regulations, and other interpretive materials for complete and current information.

Paperwork Reduction Act Statement
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
valid OMB control number for this information collection is 0938-XXXX. The time required to
complete this information collection is estimated to average xx hours per response, 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.

OMB Control Number: 0938-XXXX
Expiration Date: xx/xx/xxxx

Notice to Provider and Patient:
Selected Dispute Resolution Entity Selected by HHS
[Date]
The U.S. Department of Health and Human Services (HHS) has identified a
selected dispute resolution (SDR) entity to review the case with Reference
Number [XXXX].
[SDR entity name] has been assigned to this case. They can be contacted at:
[SDR Entity Mailing Address]
[SDR Entity Phone #]
[SDR Entity Fax #]
Within 10 business days, [Health Care Provider Name] must send [SDR
Entity Name] the following information using the dispute resolution portal:
www.cms.gov/nosurprises
• A copy of the Good Faith Estimate provided to the patient for this case
• A copy of the bill sent to the patient for the items or services under dispute
• Justification for why the billed amount was appropriate and based on
unforeseen circumstances that could not have reasonably been anticipated
when the Good Faith Estimate was provided
[Patient Name] does not need to take any action at this time.
[SDR entity’s name] stated they have no conflicts of interest for this case,
meaning they:
• Do not have a financial interest in this case and are not an employee of the
health care provider, facility, or patient.
• Did not have a familial, financial, or professional relationship with the health
care provider, facility, or patient within the last year.
• Do not have another conflict of interest with the health care provider,
facility, or patient.
If you have concerns about conflict of interest with this SDR entity, please e-mail
[HHS email]