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

No Surprise Act: IDR Process

⚠️ Notice: This information collection may be referencing outdated material.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

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
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 - 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
APPENDIX 3 Notice of Offer Data Elements.docx Other-Notice of Offer Data Elements

Information Collection (IC) Details

IC Title:	Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities	Agency IC Tracking Number:

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 2590

Information Collection 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

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 8,667	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	13,743	0	13,743
Annual IC Time Burden (Hours)	27,074	652	26,422
Annual IC Cost Burden (Dollars)	198,247	138,085	60,162

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.