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.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
ON Notice Instrument 10.23.23_clean.docx	Other-Notice of Open Negotiation
ON Notice Instrument 10.23.23_clean.docx	Other-Notice of Open Negotiation
Notice of IDR Initiation Instrument 10.23.23_clean.docx	Other-Notice of IDR Initiation
Notice of IDR Initiation Instrument 10.23.23_clean.docx	Other-Notice of IDR Initiation
IDRE Selection Response Instrument 10.23.23_clean.docx	Other-Notice of Certified IDR Entity
IDRE Selection Response Instrument 10.23.23_clean.docx	Other-Notice of Certified IDR Entity
Notice of Agreement 10.23.23_clean.docx	Other- Notice of Agreement on an Out
Notice of Agreement 10.23.23_clean.docx	Other- Notice of Agreement on an Out
APPENDIX 3 - Notice of Offer Data Elements FINAL CHANGE 2.23.23.docx	Other-Notice of Offer Data Elements
APPENDIX 3 - Notice of Offer Data Elements FINAL CHANGE 2.23.23.docx	Other-Notice of Offer Data Elements
IDR_Initiation_Webform.docx	Other-IDR Initiation Webform
IDR_Initiation_Webform.docx	Other-IDR Initiation Webform
IDR Entity Selection Response webform.docx	Other-IDR Entity Selection Response
IDR Entity Selection Response webform.docx	Other-IDR Entity Selection Response
Notice of IDR Initiation Response Instrument 10.23.23_clean.docx	Other-Notice of IDR Initiation Respo
Notice of IDR Initiation Response Instrument 10.23.23_clean.docx	Other-Notice of IDR Initiation Respo
ON Notice Response Instrument 10.23.23_clean.docx	Other-Notice of Open Negotiation Res
ON Notice Response Instrument 10.23.23_clean.docx	Other-Notice of Open Negotiation Res
Withdrawal Notice 10.23.23_clean.docx	Other-Withdrawal Notice
Withdrawal Notice 10.23.23_clean.docx	Other-Withdrawal Notice

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 2590

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	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

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 420,000

Number of Respondents for Small Entity: 369,600

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 95 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,085,700	1,058,051	27,649
Annual IC Time Burden (Hours)	1,568,963	1,514,446	54,517
Annual IC Cost Burden (Dollars)	11,141,820	10,715,078	426,742

Documents for IC

table that charts IC Documents
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.