OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

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

IC 249676 under ICR 202302-0938-001CF · OMB 1210-0169.

Documents and Forms

Documents and forms in this information collection
Document NameDocument 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
10. PPDR Payment Settlement Form Notice.docx Other-Payment Settlement Form
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 Patient
6. Appendix-HHS Vendor Management (VM) Data Elements.docx Other-HHS Vendor Management
APPENDIX 3 - Notice of Offer Data Elements FINAL CHANGE 2.23.23.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)

layout table

Information Collection Instruments:
table that charts list of 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 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-Payment Settlement Form 10. PPDR Payment Settlement Form Notice.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-HHS Vendor Management 6. Appendix-HHS Vendor Management (VM) Data Elements.docx Yes Yes Fillable Printable
Other-Notice of Offer Data Elements APPENDIX 3 - Notice of Offer Data Elements FINAL CHANGE 2.23.23.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


table that charts list of burden
  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 1 0 0 0 0 1
Annual IC Time Burden (Hours) 2 0 0 0 0 2
Annual IC Cost Burden (Dollars) 15 0 0 0 0 15

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.