Form CMS-10853 Ineligible for Patient-Provider Dispute Resolution or Ad

OMB Control Number: 0938-NEW
Expiration Date: XX/XX/XXXX

APPENDIX 1
Standard Notice: Ineligible for Patient-Provider Dispute Resolution or Additional Information
Needed
(For use by Selected Dispute Resolution Entities to Send to Uninsured (or Self-Pay) Individuals
or their Authorized Representatives beginning January 1, 2022)
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.
This notice will be used by SDR entities to inform an uninsured (or self-pay) individual or their
authorized representative that the uninsured (or self-pay) individual is not eligible for dispute
resolution or that their submission to initiate dispute resolution was incomplete. If the submission is
incomplete, the notice informs the uninsured (or self-pay) individual or their authorized representative
of what is required to establish eligibility for dispute resolution.
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.
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[SDRE logo]

[SDRE address]

Date
[Uninsured/Self-pay Individual or Authorized Representative Name]
[Uninsured/Self-pay Individual or Authorized Representative Address]
[Uninsured/Self-pay Individual or Authorized Representative City, State, Zip]

RE: Information about your Patient-Provider Dispute Resolution Case,
Reference Number: XXXXXXXX
[Uninsured (or self-pay) Individual or Authorized Representative Name],
We have received your form to start the patient-provider dispute resolution process,
Reference Number [insert number], received on [insert date].
[If rejection based on eligibility] Based on our review, you are not eligible for the patientprovider dispute process because [select all that apply from the following]

□ The bill from any provider or facility is not at least $400 more than the Good Faith
Estimate (GFE) from that provider or facility.

□ [HHS received your form / your form was postmarked] on [insert date], which was
120 calendar days (or more) after the date on the bill.

While you can’t use the patient-provider dispute resolution process for this bill, you can still
contact the health care provider or facility listed on the Good Faith Estimate to negotiate the
bill and ask for financial assistance. [END]
[If rejection based on deficiencies] Based on our review, we need more information
to process your dispute. Please send the following:
[List only deficiencies discovered]:

□ The name of the item(s) or service(s) you want to dispute
□ The date you scheduled (or requested a cost estimate for) the item(s) or services(s)
you want to dispute

□ The date you received the item(s) or service(s)
□ A short description of the item(s) or service(s)
□ A copy of the bill for the item(s) or service(s) you want to dispute

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□ A copy of the Good Faith Estimate or other documentation of the expected item(s) or
service(s) and cost(s) from your provider or facility

□ Contact information for the health care provider or facility, including name,
email address, phone number and mailing address

□ Payment of Administrative Fee
□ Other:
Please send these supporting documents or payment by {insert date that
is 21 calendar days from the date on this letter} using one of the following
options:
Online:
www.cms.gov/nosurprises/consumers

Online payments: [insert payment
information here]

Mail: [SDR Entity Address]

Mail payment: Cashier’s check or
money order payable to [SDR Entity]
Mail to: [SDR Entity Address]

Please include your reference number [reference number] on all
documents you send.
Once we receive your information, we will continue the patient-provider dispute resolution
process. If you do not respond within 21 calendar days of the date on this letter, we may reject
your request to use the patient-provider dispute process. [END]
Sincerely,
[SDR Entity]
[Address line 1]
[Address line 2]

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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.