Federal IDR Process for Air Ambulance Services

No Surprises Act: IDR Process

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0169 can be found here:

Documents and Forms

Document Name Document Type
2. Tri-dept - open negotiation period notice clean 9.28.21 (002).docx Other-Notice of Open Negotiation
3. Tri-dept - notice of IDR Initiation clean 9.28.21.docx Other-Notice of IDR Initiation
4. Tri-dept - notice of certified IDR entity selection (data elements) clean 9.28.21.docx Other-Notice of Certified IDR Entity
5. Tri-dept - notice of agreement of OON rate (data elements) clean 9.28.21.docx Other-Notice of Agreement on an Out-
6. Tri-dept - notice of offer (data elements) clean 9.28.21.docx Other-Notice of Offer

Information Collection (IC) Details

IC Title:	Federal IDR Process for Air Ambulance Services	Agency IC Tracking Number:

Is this a Common Form? Yes		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 2590

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Notice of Open Negotiation	2. Tri-dept - open negotiation period notice clean 9.28.21 (002).docx	Yes	Yes	Fillable Printable
Other-Notice of IDR Initiation	3. Tri-dept - notice of IDR Initiation clean 9.28.21.docx	Yes	Yes	Fillable Printable
Other-Notice of Certified IDR Entity Selection	4. Tri-dept - notice of certified IDR entity selection (data elements) clean 9.28.21.docx	Yes	Yes	Fillable Printable
Other-Notice of Agreement on an Out-of-Network Rate	5. Tri-dept - notice of agreement of OON rate (data elements) clean 9.28.21.docx	Yes	Yes	Fillable Printable
Other-Notice of Offer	6. Tri-dept - notice of offer (data elements) clean 9.28.21.docx	Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,450	Number of Respondents for Small Entity: 2,131

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	4,497	4,497
Annual IC Time Burden (Hours)	6,549	6,549
Annual IC Cost Burden (Dollars)	17,003	17,003

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.