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Federal IDR Process for Air Ambulance Services
No Surprise Act: IDR Process
OMB: 1210-0169
IC ID: 252195
OMB.report
TREAS/IRS
OMB 1210-0169
ICR 202203-1545-007CF
IC 252195
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0169 can be found here:
2023-11-03 - Revision of a currently approved collection
2023-02-24 - RCF Recertification
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
View RCF Information Collection (IC)
IC Title:
Federal IDR Process for Air Ambulance Services
Agency IC Tracking Number:
IC Status:
New
Obligation to Respond:
Mandatory
CFR Citation:
29 CFR 2590
Information Collection Instruments:
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-Notice of Offer
6. Tri-dept - notice of offer (data elements) clean 9.28.21.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:
2,450
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Not-for-profit institutions, Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
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
4,497
4,497
0
0
0
0
Annual IC Time Burden (Hours)
6,549
6,549
0
0
0
0
Annual IC Cost Burden (Dollars)
17,003
17,003
0
0
0
0
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.