Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities

OMB Control Number: 1210-0169
Expiration Date: 04/30/2022

APPENDIX 10
Standard Notice: Uninsured (or Self-Pay) Individual and Provider or Facility Settle on a
Payment Amount After Initiating PatientProvider Dispute Resolution
(For use by health care providers and facilities beginning January 1, 2022)
Instructions
Under Section 2799B-7 of the Public Health Service Act and its implementing regulations, the U.S.
Department of Health & Human Services (HHS) is required to establish a patient-provider dispute
resolution process where a SelectedDispute Resolution (SDR) entity can resolve a payment dispute
between individuals who are not enrolled in a group health plan, or group or individual health
insurance coverage, or a Federal health care program, or a Federal Employees Health Benefits
(FEHB) program health benefits plan (uninsured individuals), or who are not seeking to file a claim
with their group health plan, health insurance coverage, or FEHB health benefits plan (self-pay
individuals), and health care provider, facility, or provider of air ambulance services by determining
the amount such individual must pay to their health care provider, facility, or provider of air
ambulance services. Under federal criteria, SDR entities will review initiation notices to determine
that an uninsured (or self-pay) individual is eligible to dispute a bill.
This notice is for use by the health care provider or facility to notify the SDR entity in the event that
both parties agree to settle on a payment amount after the patient-provider dispute resolution process has
been initiated and prior to the SDR entity making a determination. While the determination by the
SDR entity is pending, the two (2) parties to the patient-provider dispute resolution process (the
uninsured (or self-pay) individual and their authorized representative and the health care provider or
health care facility) may agree to resolve the dispute by settling on a payment amount. When the parties
settle on the amount, federal standards require the provider or facility to notify the SDR entity no later
than three (3) business days after the date of the agreement.
HHS has developed this model notice so that providers or facilities may use it to inform SDR entities
that a settlement has been reached between an uninsured (or self-pay) individual and the health care
provider or facility. To use this model notice, the provider or facility must fill in the blanks with the
appropriate information.
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, including the HHS interim final rules
(IFR) titled Requirements Related to Surprise Billing; Part II, published on October 7, 2021.
Providers and facilities should not include these instructions with the documents they give to the
selected SDR entities.

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 1210-0169. The time required to complete
this information collection is estimated to average 1.3 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.

Health Care Provider or Facility Notice of Payment Settlement
to Selected Dispute Resolution Entity
A health care provider or facility must complete this form when they, in
partnership with the uninsured (or self-pay) individual or the
individual’s authorized representative have resolved a payment
dispute outside of the dispute resolution process.
Federal standards require health care providers and facilities notify the
Selected Dispute Resolution (SDR) entity, no later than 3 business days
after the date of the settlement.
Please complete the information about the payment agreement.
Today’s date:

/

/

SDR Entity Name:
Reference Number:
Provider or Facility Name:
Agreed Payment Amount
Date when the new payment agreement was reached:
/
/
Select one:
[ ] We agreed to a new payment amount. The final payment amount for the
uninsured (or self-pay) individual is:
$
[ ] We agreed to provide financial assistance. The final payment
amount for the uninsured (or self-pay) individual is:
$

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Uninsured (or Self-pay) Individual Information
Uninsured (or self-pay) Individual Name:
First Name
Middle Name

Last Name

(optional) Authorized Representative Name:
Health Care Provider or Facility Information
Health Care Provider or Facility Name
Street
City
Email

State

ZIP
Phone

I have included with this form (check one):
[ ] Documentation from and/or signed by the uninsured (or self-pay)
individual agreeing to the new payment amount.
[ ] I acknowledge that the final payment amount agreed upon
includes a refund for at least half the cost of the $25 administrative fee
($12.50) paid by the uninsured (or self-pay) individual or authorized
representative for the dispute resolution request.
Once you submit this form, the SDR entity will confirm receipt of
documentation and notify the uninsured (or self-pay) individual of the
reduced Administrative fee. If you have any questions email
[email protected].
For more information visit www.cms.gov/nosurprises/consumers.

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PRIVACY ACT STATEMENT: CMS is authorized to collect the information on this form and
any supporting documentation under section 2799B-7 of the Public Health Service Act, as added
by section 112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations
Act, 2021 (Pub. L. 116-260). We need the information on the form to process your request to
initiate a payment dispute, verify the eligibility of your dispute for the PPDR process, and to
determine whether any conflict of interest exists with the independent dispute resolution entity
selected to decide your dispute. The information may also be used to: (1) support a decision on
your dispute; (2) support the ongoing operation and oversight of the PPDR program; (3) evaluate
selected IDR entity’s compliance with program rules. Providing the requested information is
voluntary. But failing to provide it may delay or prevent processing of your dispute, or it could
cause your dispute to be decided in favor of the provider or facility.