Patient Provider Dispute Resolution Requirements Related to Surprise Billing: Part II (CMS-10853)

Forms and Documents

Document Name	Status
Form CMS-10853 Requirements Related to Surprise Billing; Part II; Patient-Provider Dispute Resolution Process Form and Instruction	New
CMS-10853 PPDR Supporting Statement_Final Version (July 2023) 508'ed.pdf Supporting Statement A	2023-09-11
CMS-10853 Response to public comment.pdf Supplementary Document	2023-09-11

IC Document Collections

IC ID	Document Title	Status
262051	Requirements Related to Surprise Billing; Part II; Patient-Provider Dispute Resolution Process Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202309-0938-001
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CCIIO - 10853
Title: Patient Provider Dispute Resolution Requirements Related to Surprise Billing: Part II (CMS-10853)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 09/11/2023

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	26,659	0
Time Burden (Hours)	322,189	0
Cost Burden (Dollars)	0	0

---

Abstract: The No Surprises Act adds a new Part E of title XXVII of the PHS Act establishing requirements applicable to health care providers, and facilities. Specifically, the No Surprises Act adds provisions at new PHS Act sections 2799B-6 and 2799B-7, which require providers and facilities to provide a good faith estimate of the total expected charges to uninsured individuals, under certain circumstances, upon their request, for scheduled items and services, and allow uninsured individuals to avail themselves to a patient-provider dispute resolution process if their billed charges after receiving such items or services is substantially in excess of the expected charges listed in the good faith estimate furnished by the provider ot facility. PHS Act section 2799B-6 (2)(A) requires a health care provider or facility to provide a notification of the good faith estimate of expected charges to a plan or issuer in the case the individual is enrolled in such a plan or coverage and is seeking to have a claim for such item or services submitted to such plan or coverage. The good faith estimate of expected charges from the health care provider or facility will inform the advanced explanation of benefits that must be provided by the plan or issuer, as required by PHS Act section 2799A-1(f), in the case the individual is enrolled in such a plan or coverage and is seeking to have a claim for such item or services submitted to such plan or coverage.

---

Authorizing Statute(s): PL: Pub.L. 116 - 260 116 260 Title I of Division BB Name of Law: Consolidated Appropriations Act, 2021
  

Citations for New Statutory Requirements: US Code: 45 USC 149.620 Name of Law: Surprise Billing and Transparency Requirements

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 27517	05/02/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 56023	08/17/2023
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Requirements Related to Surprise Billing; Part II; Patient-Provider Dispute Resolution Process	CMS-10853, CMS-10853, cms-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853	Ineligible for Patient-Provider Dispute Resolution or Additional Information Needed ,   Patient-Provider Dispute Resolution Form ,   SDR Entity Certification Application Data Elements ,   Vendor Management Data Elements ,   Patient-Provider Dispute Resolution Process Data Elements ,   Selected Dispute Resolution (SDR) Determination Notice ,   SDRE Selection Notice ,   Payment Settlement Form (PPDR) ,   SDRE Confirmation of Receipt of Settlement Notice ,   Request for Extension Notice

---

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	26,659	0	26,659	0	0	0
Annual Time Burden (Hours)	322,189	0	322,189	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection of information.

---

Annual Cost to Federal Government: $12,600,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/11/2023

---