Health Care Facilities on Behalf of Health Care Providers and Health Care Facilities

OMB Control No. 0938-XXXX
Expiration Date: XX/XX/XXXX
APPENDIX 6
Independent Dispute Resolution and Patient-Provider Dispute Resolution Processes;
Vendor Management
Data Elements
The Departments of the Treasury, Labor and Health and Human Services (collectively, the
Departments) and the Office of Personnel Management have issued interim final rules
establishing an independent dispute resolution (IDR) process that out-of-network or
nonparticipating health care facilities and providers (including air ambulance providers) and
group health plans and health insurance issuers of group and individual coverage may utilize
following the end of an open negotiation period. This IDR process is available only for certain
services, such as out-of-network emergency services, certain out-of-network services at an innetwork facility where sufficient notice and consent is not provided, or air ambulance services.
This IDR process is also only available if a state All-Payer Model Agreement or specified state
law does not apply.
Additionally, HHS has issued interim final rules (45 CFR 149.620) that provide protections for
the uninsured by requiring the Secretary of HHS to establish a process (referred to as patientprovider 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 health care 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 health care provider or health care facility is
billed by such health care provider or health care 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.
As part of this process, HHS is responsible for the payment of the fee to the IDR Entity. The
table below identifies data elements that an IDR Entity will be required to provide to HHS so
that the IDR Entity can pay the required administrative fee.
Note that this PRA package is for HHS’ requirements at 45 CFR 149.620.
Independent Dispute Resolution Entity Organization Data
1. Legal Business Name
2. Marketing Name (dba)
3. Tax Identification Number (TIN)
4. Unique Company Tracking ID
5. Company Address: Address
6. Company Address: Address 2
7. Company Address: City
8. Company Address: State
9. Company Address: Zip Code
10. Company Mailing Address: Address

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Company Mailing Address: Address 2
Company Mailing Address: City
Company Mailing Address: State
Company Mailing Address: Zip
Name of Holding Company

Contacts
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Main Company Contact: First Name
Main Company Contact: Last Name
Main Contact: E-mail
Main Company Contact: Phone Number
Main Contact: Phone Ext (Yes/No)
Main Company Contact: Phone Ext
CEO: First Name
CEO: Last Name
CEO: E-mail
CEO: Phone Number
CEO: Phone Ext (Yes/No)
CEO: Phone Ext
CFO: First Name
CFO: Last Name
CFO: E-mail
CFO: Phone Number
CFO: Phone Ext (Yes/No)
CFO: Phone Number Ext
Billing and Payment Contact: First Name
Billing and Payment Contact: Last Name
Billing and Payment Contact: Phone Number
Billing and Payment Contact: Phone Ext (Yes/No)
Billing and Payment Contact: Phone Number Ext
Billing and Payment Contact: E-mail

Payment and User Fee Charges Operations Data Elements for Independent Dispute Resolution
Entity
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Reason for Submission: New EFT Authorization (Y/N), Revision to
CurrentAuthorization (e.g. account or financial institution changes)
(Y/N)
Check here if EFT payment is being made to the Affiliate of the Entity
(Attachletter authorizing EFT payments to the Affiliated Entity)
Since your last EFT authorization agreement submission, have you had a
Change of Ownership and/or Change of Address? (Y/N) If yes, submit a
change of informationprior to accompanying this EFT authorization.

OMB Control No. 0938-XXXX
Expiration Date: XX/XX/XXXX
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TIN
Payee ID
Legal Business Name – Legal entity name should be the same name provided
to the Internal Revenue Service on Form W-9, Request for Taxpayer
Identification Number(TIN) and Certification
Marketing Name:
Entity: Name (DBA)
Entity: Name (Division)
Entity: Address
Entity: Address 2 – Optional demand letter routing information (e.g.
Attention:Accounting Department)
Entity: City
Entity: State
Entity: Zip Code
Entity: Country
IRS 1099: Address
IRS 1099: Address 2
IRS 1099: City
IRS 1099: State
IRS 1099: Zip Code
IRS 1099: Country
Letter from Financial Institution for Account Validation
Financial Institution Routing Transit Number (ACH only)
Entity Depositor Account Number
Type of Account: Checking or Savings
Payment Amount
Invoice Number
Invoice Date
EFT Banking Information: Title (up to four instances)
EFT Banking Information: First Name (up to four instances)
EFT Banking Information: Last Name (up to four instances)
EFT Banking Information: Phone Number (up to four instances)
EFT Banking Information: Phone Number Ext (up to four instances)
EFT Banking Information: E-mail (up to four instances)
EFT Banking Information: Bank Name (up to four instances)
EFT Banking Information: Address (up to four instances)
EFT Banking Information: Address 2 (up to four instances)
EFT Banking Information: City (up to four instances)
EFT Banking Information: State (up to four instances)
EFT Banking Information: Zip Code (up to four instances)
EFT Banking Information: Country (up to four instances)
Change of Ownership Date
Business Line to which this banking information is applicable – Also referred to as
“Business Line” or “Program Type” which includes IDRE User Fees.
Financial Reporting IP Address

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Authorized/Delegated Official: Title
Authorized/Delegated Official: First Name
Authorized/Delegated Official: Last Name
Authorized/Delegated Official: Phone Number
Authorized/Delegated Official: Phone Ext (Yes/No)
Authorized/Delegated Official: Phone Number Ext
Authorized/Delegated Official: E-mail
Authorized/Delegated Official: Signature
Date of Authorization
Payment Contact: First Name
Payment Contact: Last Name
Payment Contact: Phone Number
Payment Contact: Phone Ext (Yes/No)
Payment Contact: Phone Number Ext
Payment Contact: E-mail
Electronic Funds Transfer Authorization Agreement (check box)
Effective Date for Financial Information
Financial Authority Contact: Title
Financial Authority Contact: First Name
Financial Authority Contact: Last Name
Financial Authority Contact: Phone Number
Financial Authority Contact: Phone Ext (Yes/No)
Financial Authority Contact: Phone Ext
Financial Authority Contact: E-mail
Financial Institution: Name
Financial Institution: City
Financial Institution: State
Financial Institution: Zip
Financial Institution Contact: First Name
Financial Institution Contact: Last Name
Financial Institution Contact: Phone Number
Financial Institution Contact: Phone Ext (Yes/No)
Financial Institution Contact: Phone Number Ext
Payee Record: TIN
Payee Record Contact: Title
Payee Record Contact: First Name
Payee Record Contact: Last Name
Payee Record Contact: Phone Number
Payee Record Contact: Phone Ext (Yes/No)
Payee Record Contact: Phone Number Ext
Payee Record Contact: Email
Payee Record Contact: Address
Payee Record Billing Address: Address
Payee Record Billing Address: Attention

OMB Control No. 0938-XXXX
Expiration Date: XX/XX/XXXX
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Payee Record Billing Address: City
Payee Record Billing Address: State
Payee Record Billing Address: Zip Code
Type of Corporate Entity

Pay.gov Fields
1. Company Name
2. Entity ID/Unique Company Tracking ID
3. Invoice Number
4. Program Type
5. Address
6. City
7. State
8. Zip
9. Primary Contact Name
10. Primary Contact Phone Number
11. Primary Contact Email
12. Secondary Contact Name
13. Secondary Phone Number
14. Secondary Contact Email
15. Payment authorization attestation (check box)
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 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 1.5 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.