Patient-Provider Dispute Resolution Process

Requirements Related to No Surprise Billing Act, Part II (CMS-10791)

Documents and Forms

Document Name Document Type
7. HHS - Appendix PPDR Data Elements for Patients and Providers.pdf Other-Data Templates
8. PPDR - SDRE Determination Notice.pdf Other-Model notice
9. PPDR - SDRE Selection Notice.pdf Other-Notice
CMS-10791 - 10. PPDR - Payment Settlement Form.pdf Other-Notice

Information Collection (IC) Details

IC Title:	Patient-Provider Dispute Resolution Process	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 149.620

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Data Templates	7. HHS - Appendix PPDR Data Elements for Patients and Providers.pdf	Yes	Yes	Paper Only
Other-Model notice	8. PPDR - SDRE Determination Notice.pdf	Yes	No	Paper Only
Other-Notice	9. PPDR - SDRE Selection Notice.pdf	Yes	No	Paper Only
Other-Notice	CMS-10791 - 10. PPDR - Payment Settlement Form.pdf	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 26,659	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 34 %

	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	26,659	26,659
Annual IC Time Burden (Hours)	255,524	255,524
Annual IC Cost Burden (Dollars)	29,764,774	29,764,774

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.