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

No Surprises Act: IDR Process

OMB: 1210-0169

IC ID: 248846

Documents and Forms
Document Name
Document Type
Other-Notice of Open Negotiation
Other-Notice of IDR Initiation
Other-Notice of Certified IDR Entity
Other- Notice of Agreement on an Out
Other-Payment Settlement Form
Other-Good Faith Estimate Template N
Other-PPDR Data Elements for Patient
Other-HHS Vendor Management
Other-Notice of Offer Data Elements
Other-PPDR Dispute Initiation Form
Other-Online PPDR Initiation Form
Other-IDR Initiation Webform
Other-IDR Entity Selection Response
Information Collection (IC) Details

View Information Collection (IC)

Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities
 
Yes Modified
 
Mandatory
 
29 CFR 2590

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

Income Security General Retirement and Disability

 

17,435 15,168
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   95 %

  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 27,649 0 0 0 0 27,649
Annual IC Time Burden (Hours) 54,517 0 0 0 0 54,517
Annual IC Cost Burden (Dollars) 426,742 0 0 0 0 426,742

Title Document Date Uploaded
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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