OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities and Providers of Air Ambulance Services

IC 248846 under ICR 202305-1210-002 · OMB 1210-0169.

Documents and Forms
Document Name
Document Type
Other-Notice of Open Negotiation
Other-Notice of Open Negotiation
Other-Notice of IDR Initiation
Other-Notice of IDR Initiation
Other-Notice of Certified IDR Entity
Other-Notice of Certified IDR Entity
Other- Notice of Agreement on an Out
Other- Notice of Agreement on an Out
Other-Notice of Offer Data Elements
Other-Notice of Offer Data Elements
Other-IDR Initiation Webform
Other-IDR Initiation Webform
Other-IDR Entity Selection Response
Other-IDR Entity Selection Response
Other-Notice of IDR Initiation Respo
Other-Notice of IDR Initiation Respo
Other-Notice of Open Negotiation Res
Other-Notice of Open Negotiation Res
Other-Withdrawal Notice
Other-Withdrawal Notice
Information Collection (IC) Details

View Information Collection (IC)

Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities and Providers of Air Ambulance Services
 
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 ON Notice Instrument 10.23.23_clean.docx Yes Yes Fillable Printable
Other-Notice of IDR Initiation Notice of IDR Initiation Instrument 10.23.23_clean.docx Yes Yes Fillable Printable
Other-Notice of Certified IDR Entity Selection IDRE Selection Response Instrument 10.23.23_clean.docx Yes Yes Fillable Printable
Other- Notice of Agreement on an Out-of-Network Rate Notice of Agreement 10.23.23_clean.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-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
Other-Notice of IDR Initiation Response Notice of IDR Initiation Response Instrument 10.23.23_clean.docx Yes Yes Fillable Printable
Other-Notice of Open Negotiation Response ON Notice Response Instrument 10.23.23_clean.docx Yes Yes Fillable Printable
Other-Withdrawal Notice Withdrawal Notice 10.23.23_clean.docx Yes Yes Fillable Printable

Income Security General Retirement and Disability

 

420,000 369,600
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   95 %

  Requested 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 1,085,700 0 0 1,058,051 0 27,649
Annual IC Time Burden (Hours) 1,568,963 0 0 1,514,446 0 54,517
Annual IC Cost Burden (Dollars) 11,141,820 0 0 10,715,078 0 426,742

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.