Information Collection

Federal IDR Process for Air Ambulance Services

IC 252195 under ICR 202211-1545-003CF · 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⚠️ Notice: This information collection may be referencing outdated material.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 4.20.22 clean.docx	Other-Notice of Open Negotiation
3. Tri-dept - notice of IDR Initiation 4.20.22.docx	Other-Notice of IDR Initiation
4. Tri-dept - notice of certified IDR entity selection 4.20.22 clean.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
7. Appendix-HHS PPDR Data Elements for Patients and Providers.docx	Other- PPDR Data Elements for Patien
6. Appendix-HHS Vendor Management (VM) Data Elements.docx	Other-Vendor Management Data Element
10. PPDR Payment Settlement Form Notice.docx	Other-Payment Settlement Form Notice
Notice of Offer Data Elements 8.19.22 10.30am_CLEAN.docx	Other-Notice of Offer Data Elements
4. PPDR Dispute Initiation Form.docx	Other-PPDR Dispute Initiation Form
14. Online PPDR Initiation Form.docx	Other-Online PPDR Initiation Form
IDR_Initiation_Webform.docx	Other-IDR Initiation Webform
IDR Entity Selection Response webform.docx	Other-IDR Entity Selection Response

Information Collection (IC) Details

View RCF Information Collection (IC)

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 4.20.22 clean.docx	Yes	Yes	Fillable Printable
Other-Notice of IDR Initiation	3. Tri-dept - notice of IDR Initiation 4.20.22.docx	Yes	Yes	Fillable Printable
Other-Notice of Certified IDR Entity Selection	4. Tri-dept - notice of certified IDR entity selection 4.20.22 clean.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	7. Appendix-HHS PPDR Data Elements for Patients and Providers.docx	Yes	Yes	Fillable Printable
Other-Vendor Management Data Elements	6. Appendix-HHS Vendor Management (VM) Data Elements.docx	Yes	Yes	Fillable Printable
Other-Payment Settlement Form Notice	10. PPDR Payment Settlement Form Notice.docx	Yes	Yes	Fillable Printable
Other-Notice of Offer Data Elements	Notice of Offer Data Elements 8.19.22 10.30am_CLEAN.docx	Yes	Yes	Fillable Printable
Other-PPDR Dispute Initiation Form	4. PPDR Dispute Initiation Form.docx	Yes	Yes	Fillable Printable
Other-Online PPDR Initiation Form	14. Online PPDR Initiation Form.docx	Yes	Yes	Fillable Printable
Other-IDR Initiation Webform	IDR_Initiation_Webform.docx	Yes	Yes	Fillable Fileable
Other-IDR Entity Selection Response Webform	IDR Entity Selection Response webform.docx	Yes	Yes	Fillable Fileable

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 %

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)	7,825	1,079	6,746
Annual IC Cost Burden (Dollars)	69,403	13,363	56,040

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.