Information Collection Request
No Surprises Act: IDR Process
ICR 202302-1210-003 · OMB 1210-0169 · Active
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 1210-0169 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 IDR- No Material Justification 02-24-2023.docx |
Justification for No Material/Nonsubstantive Change | Uploaded 2023-02-24 | Available |
| Consolidated 1210-0169 Tri-dept PRA supporting statement 11.9.2022 (clean).docx |
Supporting Statement A | Uploaded 2022-11-09 | Available |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 254938 |  Additional Information to Be Shared with the Initial Payment or Notice of Denial of Payment |
Other-Disclosure Requirement | Unchanged | |
| 249371 | Request of Extension of Time Periods for Extenuating Circumstances |
Other-Request of Extension of Time Periods for Extenuating Circu | Unchanged | |
| 248857 | IDR Entity Certification and IDR Entity Monthly Reporting |
Other-IDR Certification Application | Modified | |
| 248850 | Federal IDR Process for Air Ambulance Services |
Other-Notice of Open Negotiation | Modified | |
| 248846 | Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities |
Other-Notice of Open Negotiation | Modified |
ICR Details
| Status | Active |
|---|---|
| Agency/Subagency | DOL/EBSA |
| OMB Control No | 1210-0169 |
| Type of Information Collection | No material or nonsubstantive change to a currently approved collection |
| Previous ICR Reference No | 202207-1210-004 |
| Date Submitted to OIRA | 2023-02-24 |
| Requested Expiration Date | 1969-12-31 |