cms-10853 SDR Entity Certification Application Data Elements

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

APPENDIX 3
Patient-Provider Selected Dispute Resolution (SDR) Entity Certification Application
Data Elements
The Departments of the Treasury, Labor and Health and Human Services (the Departments)
have issued the Requirements Related to Surprise Billing; Part II interim final rule (86 FR
55980), which provides protections for the uninsured. This rule requires the Secretary of
HHS to establish a process referred to as the patient-provider dispute resolution process.
Under this process, an uninsured (or self-pay) individual may seek a determination from an
SDR entity for any billed charges from a provider1 or facility that are substantially in excess
of the good faith estimate provided by that health care provider or facility in advance of
receiving the items or services. These requirements provide for an SDR entity to review
and make an independent, binding determination of the payment amount for items and
services. The SDR entity must be certified by the Secretary under 45 CFR 149.620(d).
HHS intends to contract with between 1 and 3 SDR entities that meet the certification
requirements outlined in 45 CFR 149.620(d), rather than pursue an open certification
process as is the case for certified Independent Dispute Resolution (IDR) entities in the
federal IDR process.
The table below identifies data elements that an organization seeking to become an SDR
entity is required to include in the contracting process.
DATA ELEMENT

DESCRIPTION

SDR Entity Application for Certification
General Company Information
Legal SDR entity Name and
SDR entity’s legal name as written on their business
trade name (DBA) if applicable
license, and DBA if applicable
SDR entity Address
SDR entity’s physical address, including street name and
number, city, state, and zip code
SDR entity Website
SDR entity’s uniform resource locator (URL) linked to the
home webpage (e.g., www.SDR entity.org)
Tax ID Type and Number
SDR entity’s taxpayer identification number (TIN),
employer identification number (EIN), or federal tax
identification number (FEIN) issued by the Internal
Revenue Service, and type of number
Primary Contact Information
First name, last name, phone number, and email address of
the person representing the SDR entity on the application
For ease of reference, for purposes of this document, the term “provider” should be considered to include providers
of air ambulance services.

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DATA ELEMENT
Secondary Contact Information
Expertise
Documentation to prove
expertise

DESCRIPTION
First name, last name, phone number, and email address of
an additional person, other than the primary contact,
representing the SDR entity on the application.

Verification (e.g., staff members’ resumes or CVs showing
experience) that SDR entity has requisite medical and legal
expertise, including in health care and air-space laws, and
sufficient experience in arbitration and claims
administration, managed care, and billing and coding.
Additional documentation of expertise and other supporting
materials may be submitted for consideration.*
Organization Structure and Staffing Plan
Organization Chart
A graphic representation of the structure of the SDR entity
showing the hierarchy of the organization and the
relationships within it, including any parent or subsidiary
entities. SDR entities must not be owned by a subsidiary
of, or associated or affiliated with a plan, issuer, provider,
provider of air ambulance services.
Staffing Plan
Document that describes the credentials, responsibilities,
and number of personnel employed to make determinations.
This should also include policies and procedures governing
the allocation of staff to case arbitration, including the
credentials and responsibilities of staff that will be
arbitrating cases, as well as policies and procedures for
ensuring proper verification of credentials. Documentation
should also show operations and infrastructure to
effectively and efficiently manage the arbitration process,
including delegation of functions and oversight of the
process, and applicable procedures for using contractors to
fill expertise vacancies so determinations can be completed
within the required time period.
Conflict of Interest Attestation
Organizational Attestation of No An attestation indicating the SDR entity is not (1) a
provider or a facility; (2) not an affiliate or subsidiary of a
Conflicts of Interest
provider or a facility; or (3) an affiliate or subsidiary of a
professional or trade association representing providers or
facilities.
Indicators of Fiscal Integrity and Stability
Documentation describing a system of safeguards and
Documentation to prove fiscal
controls in place to prevent and detect improper financial
integrity and stability
activities by employees and other affiliated persons to
assure the fiscal integrity and accountability for all fees
received and held, and three most recent years of SDR
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DATA ELEMENT

Internal Controls to Hold Fees
Internal Controls to Hold
Administrative Fees

DESCRIPTION
entity’s balance sheets, income statements, cash flow
statements, and statements of changes in owners’ equity (if
applicable) or other documentation to demonstrate fiscal
stability.
Policies and procedures to retain the administrative fees
paid by the initiating party during the initiation of the
dispute resolution process, remit funds to CMS, and prevent
fraud, abuse, or waste of funds held.

Conflict of Interest Audit Standards
Conflict of Interest Mitigation
Information on the SDR entity’s conflict-of-interest policies
Policies
and procedures, including outlining a mitigation plan in the
event of an entity-level conflict of interest, under which no
dispute resolution personnel affiliated with the SDR entity
can fairly and impartially adjudicate a case, in compliance
with the standards in Federal Acquisition Regulation
subpart 9.5
Proof of Accreditation or Arbitration Training
Documentation proving current accreditation by a certified
Document(s) to demonstration
accreditation body, such as URAC, or that the SDR entity
proof of Accreditation or
otherwise possesses the requisite training to conduct
Arbitration Training
payment determinations (for example, providing
documentation that personnel have competed arbitration
training by the American Arbitration Association,
American Health Law Association, or a similar
organization).
Confidential Health Information
Confidential Health Information Written policies and procedures to protect the
confidentially of IIHI as outlined in the interim final rules
Standards
for Requirements Related to Surprise Billing: Part II,
including how the certified SDR Entity will: ensure the
confidentiality, integrity, and availability of all IIHI they
create, obtain, maintain, store, or transmit; protect against
any reasonably anticipated threats or hazards to the security
or integrity of IIHI; protect against unauthorized use or
disclosure of IIHI by their personnel; securely destroy or
dispose of IIHI; monitor, periodically assess, and update
security controls and related systems risks to ensure the
continued effectiveness of those controls; and in the event
of a breach in unsecure IIHI, conduct a risk assessment to
determine the nature and extent of the breach, and provide
notifications to the Departments and all parties affected by
the breach.
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DATA ELEMENT

DESCRIPTION

Internal Controls to Support Reporting Compliance
Reporting Plan
Policies and procedures outlining your organization’s
ability to comply with reporting requirements found in the
SDR entity’s contract with CMS, including properly
collecting and storing all required information and how this
will be reported to the Departments.
Policies and Procedures for Subcontracting
Subcontractor Management Plan Documentation describing the organization’s policies and
procedures for managing subcontractors, including how the
organization will ensure that subcontractors assigned to a
determination do not have a conflict of interest regarding
any party to the dispute, and how the organization will
ensure that subcontractors protect IIHI, in the same manner
as required of certified SDR entities.
Policies and Procedures for Compliance with Federal Civil Rights Laws
Nondiscrimination Policies and
Policies and procedures for ensuring compliance with
Procedures
federal civil rights laws that prohibit discrimination to the
extent applicable, including section 1557 of the Affordable
Care Act, title VI of the Civil Rights Act of 1964, sections
504 and 508 of the Rehabilitation Act of 1973.
Contract with Secretary to Meet Certified SDR Entity Standards and Procedures
Standards and Procedures as
Contract detailing standards and procedures determined by
Determined by the Secretary
the Secretary through guidance for SDR entities.
*Denotes optional submission

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 of 5.25 hours per respondent, 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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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.