Information Collection

Federal IDR Process for Air Ambulance Services

IC 252195 under ICR 202204-1545-001CF · 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⚠️ Notice: This information collection may be referencing outdated material.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
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 - 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 Patien
CMS-10791 - Appendix-HHS Vendor Management (VM) Data Elements.pdf	Other-Vendor Management Data Element
CMS-10791- PPDR-Payment Settlement Form Notice.pdf	Other-Payment Settlement Form Notice
APPENDIX 3 Notice of Offer Data Elements.docx	Other-Notice of Offer Data Elements

IC Title:

Federal IDR Process for Air Ambulance Services

Agency IC Tracking Number:

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-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

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 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,497	0	4,497
Annual IC Time Burden (Hours)	6,746	197	6,549
Annual IC Cost Burden (Dollars)	56,040	39,037	17,003

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.