Information Collection

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

IC 248846 under ICR 202202-1210-002 · OMB 1210-0169.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
2. Tri-dept - open negotiation period notice clean 9.28.21 (002).docx	Other-Notice of Open Negotiation
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
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
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
5. Tri-dept - notice of agreement of OON rate (data elements) clean 9.28.21.docx	Other- Notice of Agreement on an Out
CMS-10791- PPDR-Payment Settlement Form Notice.pdf	Other-Payment Settlement Form
CMS-10791- PPDR-Payment Settlement Form Notice.pdf	Other-Payment Settlement Form
CMS-10791 - Good Faith Estimate Template Notice.pdf	Other-Good Faith Estimate Template N
CMS-10791 - Good Faith Estimate Template Notice.pdf	Other-Good Faith Estimate Template N
CMS-10791 - Appendix-HHS PPDR Data Elements for Patients and Providers_v2.pdf	Other-PPDR Data Elements for Patient
CMS-10791 - Appendix-HHS PPDR Data Elements for Patients and Providers_v2.pdf	Other-PPDR Data Elements for Patient
CMS-10791 - Appendix-HHS Vendor Management (VM) Data Elements.pdf	Other-HHS Vendor Management
CMS-10791 - Appendix-HHS Vendor Management (VM) Data Elements.pdf	Other-HHS Vendor Management
APPENDIX 3 Notice of Offer Data Elements.docx	Other-Notice of Offer Data Elements
APPENDIX 3 Notice of Offer Data Elements.docx	Other-Notice of Offer Data Elements

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 2590

Information Collection Instruments:

table that charts list of 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-Payment Settlement Form	CMS-10791- PPDR-Payment Settlement Form Notice.pdf	Yes	Yes	Fillable Printable
Other-Good Faith Estimate Template Notice	CMS-10791 - Good Faith Estimate Template Notice.pdf	Yes	Yes	Fillable Printable
Other-PPDR Data Elements for Patients and Providers	CMS-10791 - Appendix-HHS PPDR Data Elements for Patients and Providers_v2.pdf	Yes	Yes	Fillable Printable
Other-HHS Vendor Management	CMS-10791 - Appendix-HHS Vendor Management (VM) Data Elements.pdf	Yes	Yes	Fillable Printable
Other-Notice of Offer Data Elements	APPENDIX 3 Notice of Offer Data Elements.docx	Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 8,718

Number of Respondents for Small Entity: 7,584

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	13,825	82	13,743
Annual IC Time Burden (Hours)	27,259	837	26,422
Annual IC Cost Burden (Dollars)	199,430	139,268	60,162

Documents for IC

table that charts IC Documents
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.