CMS-10853 SDRE Selection Notice (English)

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

APPENDIX 7
Standard Notice: Selected Dispute Resolution (SDR) Entity Notification to Health Care Providers
and Facilities and Uninsured (or Self-Pay) Individuals
(For use by SDR Entities beginning January 1, 2022)
Instructions
Under Section 2799B-7 of the Public Health Service Act, the U.S. Department of Health & Human
Services (HHS) is required to establish a patient-provider dispute resolution process where an SDR
entity can resolve a payment dispute between health care providers,1 or health care facilities and
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 (uninsured
individuals), or individuals who are enrolled but not seeking to file a claim with their group health plan
or health insurance coverage, or FEHB health benefits plan (self-pay individuals) by determining the
amount such individual s must pay their health care provider or facility. Under federal criteria, once
HHS determines that an individual is eligible to dispute billed charges, HHS must select an SDR entity
for the dispute resolution.
Once HHS assigns an SDR entity to a dispute, the SDR entity must inform both parties (the uninsured
(or self-pay) individual and the health care provider or health care facility) of the selection.
Additionally, the SDR entity must request that the health care provider submit specific information
within 10 business days of receipt of the notice so the SDR entity can use the data to make a
determination on the dispute.
HHS has developed this standard notice so that providers or facilities and uninsured (or self-pay)
individuals are informed of the SDR entity selection. To use this standard notice, the SDR entity, must
fill in the blanks with the appropriate information.
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, including the HHS
interim final rules (IFR) titled Requirements Related to Surprise Billing; Part II, published on October 7,
2021.
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.

For ease of reference, for purposes of this document, the term “provider” should be considered to include providers of air
ambulance services.

1

Notice to Provider or Facility
and Uninsured (or Self-pay) Individual:
Selected Dispute Resolution Entity Selected by HHS
[Date]
The U.S. Department of Health and Human Services (HHS) received a patient-provider
dispute resolution initiation notice identifying you as parties in this matter. HHS has
identified a selected dispute resolution (SDR) entity to review the case; your case
Reference Number is [XXXX].
[SDR entity name] has been assigned to this case. They can be contacted at:
[SDR Entity Mailing Address]
[SDR Entity Phone #]
[SDR Entity Fax #]
[INCLUDE IF THE RECIPIENT OF THIS NOTICE IS THE PATIENT]
[UNINSURED (OR SELF-PAY) INDIVIDUAL NAME] does not need to take any action at this
time.
[INCLUDE IF THE RECIPIENT OF THIS NOTICE IS THE PROVIDER OR FACILITY]
•
•
•
•

Full Name of Patient
Date Initiation Notice was received
Last 4 digits of the Reference Number/Invoice Number/ Account Number on the bill the
patient provided
Items or services under dispute

Within 10 business days, [Health Care Provider / Facility Name] must send [SDR
Entity Name] the following information. You are strongly encouraged to use the dispute
resolution portal.

• A copy of the Good Faith Estimate provided to the patient for this case
• A copy of the bill sent to the patient for the items or services under dispute
• Justification for why the billed amount was appropriate and based on unforeseen

circumstances that could not have reasonably been anticipated when the Good Faith
Estimate was provided

[FOR BOTH UNINSURED (OR SELF-PAY) INDIVIDUAL AND PROVIDER OR FACILITY]
At any point after the dispute resolution process has been initiated but before the SDR entity
makes a determination, the parties can settle on their own payment amount. In the event that
the parties agree to settle on a payment amount, [health care provider / facility name] should
notify the SDR entity through the dispute resolution portal, electronically, or in paper form, as

soon as possible, but no later than 3 business days after the date of the agreement.
The settlement notification must contain the settlement amount, the date upon which
settlement was reached, and documentation demonstrating that the provider or
facility and uninsured (or self-pay) individual have agreed to the settlement. The
settlement notice must also document that the provider or facility has applied a
reduction to the uninsured (or self-pay) individual’s settlement amount that is equal to
at least half the amount of the administrative fee. You can call 1-800-985-3059 to
learn more about the settlement notice.
[SDR entity’s name] stated they have no conflicts of interest for this case, meaning
they:

• Do not have a financial interest in this case and are not an employee of the health care
provider, facility, or uninsured (or self-pay) individual.
• Did not have a familial, financial, or professional relationship with the health care
provider, facility, or uninsured (or self-pay) individual within the last year.
• Do not have another conflict of interest with the health care provider, facility, or
uninsured (or self-pay) individual.

If you have concerns about conflict of interest with this SDR entity, e-mail
[email protected].
For more information, visit www.cms.gov/nosurprises/consumers

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.