CMS-10853 Patient-Provider Dispute Resolution Process Data Element

APPENDIX 5

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

Patient-Provider Dispute Resolution Process
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 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 a
Selected Dispute Resolution (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 for purposes of the PRA data elements that an uninsured (or selfpay) individual, provider, or facility is required to include in the patient-provider dispute
resolution process under 45 CFR 149.620.
RESPONSIBLE
DATA ELEMENT
PARTY
Provider or Facility Copy of the Good Faith
Estimate

DESCRIPTION

Provider or Facility Copy of the Billed Charges

A copy of the notification of expected
charges for a scheduled or requested
item or service, including items or
services that are reasonably expected
to be provided in conjunction with
such scheduled or requested item or
service, provided by a co-health care
provider or co-health care facility
consistent with statutory provisions in
PHS Act section 2799B-6(2) and 45
CFR 149.620.
A copy of the billed charges provided
to the uninsured (or self-pay)
individual for the item or service
under dispute.

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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RESPONSIBLE
DATA ELEMENT
PARTY
Provider or Facility Justification for the
Difference Between the
Good Faith Estimate and the
Bill

Provider or Facility

Uninsured (or SelfPay) Individual
Uninsured (or SelfPay) Individual

Uninsured (or SelfPay) Individual

DESCRIPTION

If available, documentation to
demonstrate that the difference
between the billed charges and the
expected charges reflects the costs of
a medically necessary qualified item
or service and is based on unforeseen
circumstances that could not have
reasonably been anticipated by the
provider or facility when the good
faith estimate was provided.
Contact Information of the Contact information of the health care
provider or health care facility
Health Care Provider or
Health Care Facility (if not involved, including name, email
address, phone number, and mailing
included in Good Faith
address, in the event that it is not
Estimate)
included in the good faith estimate.
Information on the Item or Information sufficient to identify the
item or service under dispute,
Service Under Dispute
including the date of service or the
date the item was provided.
Copy of the Provider’s or
A copy of documentation showing
Facility’s Total Billed
the total billed charges, by each heath
Charges for the Items or
care provider or health care facility,
Services
for all primary items or services that
were provided to an uninsured (or
self-pay) individual and all other
items and services furnished in
conjunction with the primary items
and services, regardless of whether
such items or services were included
in the good faith estimate.
Information sufficient for the
Last 4 digits of Account
provider or facility to identify the
Number on bill with
disputed cost item or service correct patient and provide the SDR
entity with the requested information
to conduct the PPDR process.

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RESPONSIBLE
DATA ELEMENT
PARTY
Uninsured (or Self- Copy of the Good Faith
Pay) Individual
Estimate

DESCRIPTION

Uninsured (or Self- Contact Information of the
Pay) Individual
Parties Involved

Uninsured (or Self- State Where the Item or
Pay) Individual
Service in Dispute Was
Furnished
Uninsured (or Self- Communication Preference
Pay) Individual

A copy of the notification of expected
charges for a scheduled or requested
item or service, including and items
or services that are reasonably
expected to be provided in
conjunction with such scheduled or
requested item or service, provided
by a co-health care provider or cohealth care facility consistent with
statutory provisions in PHS Act
section 2799B-6(2) and 45 CFR
149.620.
Contact information for the uninsured
(or self-pay) individual and of the
providers and facilities involved,
including name, email address, phone
number, and mailing address in the
event that it is not included in the
good faith estimate.
The State where the item or service in
dispute was furnished, in the event
that it is not included in the good
faith estimate.
The uninsured (or self-pay)
individuals communication
preference, through the federal IDR
portal, or electronic or paper mail.

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 13.5 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 C426-05, 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.