Requirements Related to No Surprise Billing Act, Part II (Independent Dispute Resolution Process) (CMS-10791)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability

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IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
249679	Request of Extension of Time Periods for Extenuating Circumstances	Other-Request of Extension of Time Periods for Extenuating Circu	New
249678	IDR Entity Certification and IDR Entity Monthly Reporting	Other-IDR Certification Application	New
249677	Federal IDR Process for Air Ambulance Services	Other-Notice of Open Negotiation	New
249676	Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities	Other-Notice of Open Negotiation	New

ICR Details

OMB Control No: 1210-0169	ICR Reference No: 202110-0938-001CF
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Requirements Related to No Surprise Billing Act, Part II (Independent Dispute Resolution Process) (CMS-10791)
Type of Information Collection: RCF New	Common Form ICR:
Type of Review Request:
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/26/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/21/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2022
Responses	8,853,972	0	0
Time Burden (Hours)	12,894,074	0	0
Cost Burden (Dollars)	33,476,812	0	0

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Abstract:

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Authorizing Statute(s): PL: Pub.L. 116 - 260 103 and 105 Name of Law: Consolidated Appropriations Act, 2021
  

Citations for New Statutory Requirements: PL: Pub.L. 105 - 105 No Surprises Act Name of Law: Consolidated Appropriations Act, 2021

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR?

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Federal IDR Process for Air Ambulance Services
Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities
IDR Entity Certification and IDR Entity Monthly Reporting
Request of Extension of Time Periods for Extenuating Circumstances

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	8,853,972	0	0	3,486,717	5,367,255	0
Annual Time Burden (Hours)	12,894,074	0	0	1,869,193	11,024,881	0
Annual Cost Burden (Dollars)	33,476,812	0	0	31,044,714	2,432,098	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new ICR associated with the common form.

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Annual Cost to Federal Government: $6,000,000

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Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.    

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.    

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR: 

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date:

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