IDR Entity Certification and IDR Entity Monthly Reporting

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

APPENDIX 12
Standard Notice: Selected Dispute Resolution (SDR) Entity Notification to Health Care
Provider or Facility and Uninsured (or Self-Pay) Individual Confirming Receipt of Dispute
Settlement and Action
(For use by SDR Entities 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 Selected Dispute 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.
Any point after the dispute resolution process has been initiated but before the date on which a
determination is made by the SDR entity, the parties can settle the payment amount through either an
offer of financial assistance or an offer to accept a lower amount, or an agreement by the uninsured
(or self-pay) individual to pay the billed charges in full. In the event that the parties agree to settle on
a payment amount, the provider or facility should notify the SDR entity through the federal IDR
Portal, electronically, or in paper form, as soon as possible, but no later than 3 business days after the
date of the agreement.
This notice is for use by the SDR entity to notify the health care provider or facility and uninsured (or
self-pay) individual that the settlement agreement has been received and the dispute is closed or the
SDR entity requires additional information from the parties.
HHS has developed this standard notice so that providers or facilities and uninsured (or self-pay)
individuals can confirm that the SDR entity has received their settlement agreement and has either
closed their case or requires more information. To use this standard notice the SDR entity 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.

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.

Selected Dispute Resolution (SDR) Entity Notification to Health Care Provider or
Facility and Uninsured (or Self-Pay) Individual Confirming Receipt of Dispute
Settlement and Corresponding Action
Date
Uninsured (or self-pay) individual or Authorized Representative Name
Uninsured (or self-pay) individual or Authorized Representative Address
Uninsured (or self-pay) individual or Authorized Representative City, State, Zip
Health care Provider or Facility Name
Health care Provider or Facility Address
Health care Provider or Facility Name City, State, Zip
RE: Patient-provider dispute resolution process settlement decision re:
Reference Number:XXXXXXXX
[Uninsured (or self-pay) individual or Authorized Representative Name], [Health care Provider
or Facility Name]
We have received and reviewed the Settlement information for [Reference Number:
XXXXXXXX] submitted by [Health Care Provider or Facility Name].

□ [Check this box if all information is included.] The Settlement agreement meets all

requirements. The [uninsured (or self-pay) individual (or authorized representative)
name] has agreed to pay [enter amount uninsured (or self-pay) individual has agreed to
pay] for [disputed item or service]. This dispute is considered settled and closed and the
agreed upon payment amount shall apply.

This decision is binding, unless there are claims of fraud or a misrepresentation of facts
presented to us, in which case you may have the right to other legal remedies. Also, [health
care provider or facility name] may provide financial assistance or agree to an offer for a lower
payment amount, or [Uninsured (or self-pay) individual name] may agree to pay the billed
charges in full, or may agree with [health care provider or facility name] on a different payment
amount. For more information, see www.cms.gov/nosurprises/consumers.

□ [Check this box if information is missing.] The Settlement agreement is missing
information. [Health care Provider or Facility Name] should provide the missing
item(s) identified below:

□ The agreed upon settlement amount the uninsured (or self-pay) individual
will pay

□ The date the settlement was reached
□ Documentation demonstrating that the provider or facility and uninsured

(or self-pay) individual have agreed to the settlement
□ Demonstration that a reduction of at least half the amount of the
administrative fee has been applied to the patient’s final payment amount
□ Other, explain:
Sincerely,
[SDR Entity Name], Selected Dispute Resolution Entity
[Company email]
[Company phone]
[Company Fax #]
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.