Request of Extension of Time Periods for Extenuating Circumstances

OMB Control Number: 0938-NEW

Expiration Date: XX/XXXX

Appendix 13

Standard Notice: Uninsured (or Self-Pay) Individual, Provider or Facility’s Notification to Secretary of Health and Human Services Requesting Extension

Instructions

Under Section 2799B-7 of the Public Health Service Act and its implementing regulations, the U.S. Department of Health & Human Services (HHS) is required to establish a patient-provider dispute resolution process where a Selected Dispute Resolution (SDR) entity can resolve a payment dispute between individuals who are not enrolled in a group health plan, or group or individual health insurance coverage, or a Federal health care program, or a Federal Employees Health Benefits (FEHB) program health benefits plan (uninsured individuals), or who are not seeking to file a claim with their group health plan, health insurance coverage, or FEHB health benefits plan (self-pay individuals), and health care provider, facility, or provider of air ambulance services by determining the amount such individual must pay to their health care provider, facility, or provider of air ambulance services. Under federal criteria, SDR entities will review initiation notices to determine that an uninsured (or self-pay) individual is eligible to dispute a bill.

An uninsured (or self-pay) individual can request an extension at any step in the patient-provider dispute resolution process by submitting a request due to extenuating circumstances to the Secretary of HHS via the federal IDR portal, or electronic or paper mail. If the uninsured (or self-pay) individual is able to demonstrate the extension is necessary to address delays due to matters beyond their control or for good cause, the Secretary has the discretion to provide such an extension.

A provider or facility may request an extension after the patient-provider dispute resolution has started. Once a dispute has been initiated, the parties may request an extension by submitting a request for extension due to extenuating circumstances through the Federal IDR portal, or electronic or paper mail if the extension is necessary to address delays due to matters beyond the control of the parties or for good cause.

Extensions cannot be granted on payment-related deadlines, including payment of the administrative fee.

Once the patient-provider dispute resolution process has started, the Secretary will consider granting extensions in the following circumstance:

(i) An extension is necessary to address delays due to matters beyond the control of the parties or for good cause; and

(ii) The parties attest that prompt action will be taken to ensure that the determination under this section is made as soon as administratively practicable under the circumstances.

This notice can be used by the uninsured or (self-pay) individual or the provider or facility to request an extension from HHS. To use this standard notice, the uninsured or (self-pay) individual or the provider or facility must provide the asked for information in the space allotted.

NOTE: The information provided in these instructions is intended only to be a general informal summary of technical legal standards. It is not intended to take the place of the statutes, regulations, or formal policy guidance upon which it is based. Readers should refer to the applicable statutes, regulations, and other interpretive materials for complete and current information.

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 1210-0169. The time required to complete this information collection is estimated to average 1.3 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Uninsured (or Self-Pay) Individual, Provider or Facility’s Notification to Secretary of Health and Human Services Requesting Extension

Uninsured (or Self-Pay) Individual [To be filled out by Uninsured (or Self-Pay) Individual]
Uninsured (or Self-Pay) Individual First Name Middle Name Last Name
(optional) Authorized Representative Name:
Uninsured (or Self-Pay) Individual’s Contact Information (or Authorized Representative if Authorized Representative Name is provided above)
Street or P.O. Box					Apartment
City			State		ZIP Code
Phone		Email
Contact Preference: [ ] By mail [ ] By email [ ] By phone
Provider/Facility (if applicable) [To be filled out by provider/facility]
Provider/Facility Name		Provider/Facility Type
Street Address
City	State			ZIP Code
Contact Person	Phone			Email
Contact Preference: [ ] By mail [ ] By email [ ] By phone

Please check the box that best applies to you and fill in the needed information.
	I am an uninsured (or self-pay) individual who wants to initiate a dispute. I am requesting an extension to initiate the process and below is my extenuating circumstance reason.
Extenuating circumstance:
	I am an uninsured (or self-pay) individual who has successfully initiated a dispute and I request an extension to submit documentation (please provide the below information and attestation).
My Dispute Reference Number
Extenuating circumstance is:
	I attest that prompt action will be taken to re-engage the process as soon as administratively practicable under the circumstances.
	I am a provider/facility; I am requesting an extension to submit supporting documentation (please provide the below information and attestation).
Dispute Reference Number
Extenuating circumstance is:
	I attest that prompt action will be taken to re-engage the process as soon as administratively practicable under the circumstances.

You may submit this request for an extension due to extenuating circumstances by using the Federal IDR portal, or via electronic or paper mail.

Electronic mail: [email protected]

Paper mail: [SDR Entity’s Address]

PRIVACY ACT STATEMENT:  CMS is authorized to collect the information on this form and any supporting documentation under section 2799B-7 of the Public Health Service Act, as added by section 112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260). We need the information on the form to process your request to initiate a payment dispute, verify the eligibility of your dispute for the PPDR process, and to determine whether any conflict of interest exists with the independent dispute resolution entity selected to decide your dispute. The information may also be used to:  (1) support a decision on your dispute; (2) support the ongoing operation and oversight of the PPDR program; (3) evaluate selected IDR entity’s compliance with program rules. Providing the requested information is voluntary. But failing to provide it may delay or prevent processing of your dispute, or it could cause your dispute to be decided in favor of the provider or facility.