No Surprises Act: IDR Process

ICR 202302-1210-003

OMB: 1210-0169

Federal Form Document

⚠️ Notice: This information collection may be outdated.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

Forms and Documents

Document Name	Status
IDR- No Material Justification 02-24-2023.docx Justification for No Material/Nonsubstantive Change	2023-02-24
Consolidated 1210-0169 Tri-dept PRA supporting statement 11.9.2022 (clean).docx Supporting Statement A	2022-11-09

IC Document Collections

IC ID	Document Title	Status
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

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