Federal IDR Process for Air Ambulance Services

No Surprises Act: IDR Process

OMB: 1210-0169

IC ID: 248850

Documents and Forms
Document Name
Document Type
Other-Notice of Open Negotiation
Other-Notice of Open Negotiation
Other-Notice of IDR Initiation
Other-Notice of IDR Initiation
Other-Notice of Certified IDR Entity
Other-Notice of Certified IDR Entity
Other-Notice of Agreement on an Out-
Other-Notice of Agreement on an Out-
Other-Good Faith Estimate Template N
Other-Good Faith Estimate Template N
Other- PPDR Data Elements for Patien
Other- PPDR Data Elements for Patien
Other-Vendor Management Data Element
Other-Vendor Management Data Element
Other-Payment Settlement Form Notice
Other-Payment Settlement Form Notice
Other-Notice of Offer Data Elements
Other-Notice of Offer Data Elements
Information Collection (IC) Details

View Information Collection (IC)

Federal IDR Process for Air Ambulance Services
 
Yes Modified
 
Mandatory
 
29 CFR 2590

Document Type Form No. Form Name Instrument File URL 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-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-Vendor Management Data Elements CMS-10791 - Appendix-HHS Vendor Management (VM) Data Elements.pdf Yes Yes Fillable Printable
Other-Payment Settlement Form Notice CMS-10791- PPDR-Payment Settlement Form Notice.pdf Yes Yes Fillable Printable
Other-Notice of Offer Data Elements APPENDIX 3 Notice of Offer Data Elements.docx Yes Yes Fillable Printable

Income Security General Retirement and Disability

 

2,484 2,161
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 4,560 0 0 63 0 4,497
Annual IC Time Burden (Hours) 6,835 0 0 286 0 6,549
Annual IC Cost Burden (Dollars) 56,825 0 0 39,822 0 17,003

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No associated records found
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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