CMS-10853 PPDR Supporting Statement_Final Version (July 2023) 508'ed

Supporting Statement—Part A
Patient Provider Dispute Resolution Requirements Related to Surprise Billing; Part II
CMS-10853/OMB control number: 0938-NEW
A.

Background

On December 27, 2020, the Consolidated Appropriations Act, 2021 (CAA), which includes the
No Surprises Act, was signed into law. The No Surprises Act provides Federal protections against
surprise billing and limits out-of-network cost sharing under many of the circumstances in which surprise
bills arise most frequently.
The Act adds a new Part E of title XXVII of the Public Health Service Act establishing
requirements applicable to providers, and facilities. These include provisions at new PHS Act sections
2799B-6 which requires providers and facilities to furnish a good faith estimate of expected charges upon
request or upon scheduling an item or service for an individual. Providers and facilities are required to
inquire if an individual is enrolled in a group health plan, group or individual health insurance coverage, a
Federal Employees Health Benefits (FEHB) plan, 1 or a Federal health care program and if enrolled in a
group health plan, or group or individual health insurance coverage, or a health benefits plan under
chapter 89 of title 5, 2 whether the individual is seeking to have a claim for such item or service submitted
to such plan or coverage (hereafter referred to as an “uninsured (or self-pay) individual”). In the case that
an uninsured (or self-pay) individual requesting a good faith estimate for an item or service or schedules
an item or service to be furnished, PHS Act section 2799B-6(2)(B) and the October 2021 interim final
rules at 45 CFR 149.610 3 require providers and facilities to furnish the good faith estimate to the
uninsured (or self-pay) individual.
No Surprises Act Section 112 also adds PHS Act section 2799B-7 as added by the interim final
rules at 45 CFR 149.620 4 which directs the Secretary of HHS to establish a process under which an
uninsured (or self-pay) individual can avail themselves of a patient-provider dispute resolution (PPDR)
process if their billed charges after receiving an item or service are substantially in excess of the expected
charges listed in the good faith estimate furnished by the provider or facility, pursuant to PHS Act section
2799B-6.

1
HHS interprets the requirements described in PHS Act section 2799B-6 to apply with respect to FEHB covered
individuals as they would to other individuals enrolled in a group health plan, group or individual health insurance
coverage offered by a health insurance issuer. Although PHS Act section 2799B-6 does not reference health benefits
plans under chapter 89 of title 5, the definition of “uninsured individual” at PHS Act section 2799B-7 does include
individuals who do not have benefits under these health benefits plans, and these sections work together to provide
protections for the uninsured (or self-pay) population. Moreover, the requirement for the provision of an advance
explanation of benefits required by PHS Act section 2799A-(1)(f), ERISA section 716(f), and Code section
9816(f)and 5 U.S.C. 8902(p) cannot be accomplished by a FEHB carrier unless it receives a good faith estimate
from a provider in accordance with PHS Act section 2799B-6(2)(A).
2
A health benefits plan offered under chapter 89 of title 5, United States Code is also known as a Federal
Employees Health Benefits (FEHB) plan.
3
https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-B/part-149/subpart-G/section-149.610
4
https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-B/part-149/subpart-G/section-149.620

1

This information collection request (ICR) focuses on the patient-provider dispute resolution
process requirements under the October 2021 interim final rules (October 7, 2021, 86 FR 55980). Based
on the legislative and regulatory authority outlined above, the requirements are summarized as follows:
•

B.

A patient-provider dispute resolution process for uninsured (or self-pay) individuals who
receive a final bill from a provider or facility that is substantially in excess of the furnished
good faith estimate. (45 CFR 149.620)
o
See Appendix 1. Selected Dispute Resolution (SDR) Entity Declining Eligibility or
Need More Information Notice; Appendix 2. PPDR Dispute Initiation Form;
Appendix 3. SDR Entity Certification Data Elements; Appendix 4. HHS Vendor
Management (VM) Data Elements; Appendix 5. PPDR Data Elements for Patients
and Providers; Appendix 6. SDR Entity Determination Notice; Appendix 7. SDR
Entity Selection Notice; Appendix 8. PPDR Payment Settlement Form; Appendix 9.
SDR Entity Confirmation of Receipt of Settlement Information; Appendix 10.
Request for Extension

Justification

1. Need and Legal Basis
On December 27, 2020, the Consolidated Appropriations Act, 2021 (CAA), which includes the
No Surprises Act, was signed into law. The No Surprises Act provides Federal protections against
surprise billing and limits out-of-network cost sharing under many of the circumstances in which surprise
bills arise most frequently.
The No Surprises Act also includes provisions that require health care providers and health care
facilities to furnish good faith estimates upon request or upon scheduling items or services to uninsured
(or self-pay) individuals. In order to implement these good faith estimate provisions under PHS Act
section 2799B-6(1) and 2799B-6(2)(B), as added by section 112 of the No Surprises Act, HHS is adding
45 CFR 149.610 to establish requirements for providers and facilities to specifically inquire about an
individual’s health coverage status and establish requirements for providing a good faith estimate to
uninsured (or self-pay) individuals.
PHS Act section 2799B-6(2) and the October 2021 interim final rules specify that a provider or
facility must provide a notification (in clear and understandable language) of the good faith estimate of
the expected charges for furnishing such items or services (including any items or services that are
reasonably expected to be provided in conjunction with such scheduled items or services and such items
or services reasonably expected to be so provided by another health care provider or health care facility),
with the expected billing and diagnostic codes (i.e., ICD, CPT, HCPCS, DRG, and/or NDC codes) for any
such items or services. The definitions related to good faith estimates of expected charges for uninsured
(or self-pay) individuals for scheduled items and services and upon request, requirements for the
providers and facilities, timing, and good faith estimate content requirements are set forth in PHS Act
section 2799B-6 and implementing regulation at 45 CFR 149.610, established under the October 2021
interim final rules.
PHS Act section 2799B-7, as added by section 112 of the No Surprises Act, provides further
protections for uninsured (or self-pay) individuals by requiring the Secretary of HHS to establish a
process (in this section referred to as patient-provider dispute resolution) under which an uninsured (or

2

self-pay) individual who received from a provider or facility, a good faith estimate of the expected
charges, and who, after being furnished the item or service, is billed for charges that are substantially in
excess of the estimate, may seek a determination from an SDR entity of the amount of charges to be paid.
HHS is adding new 45 CFR 149.620 to implement the patient-provider dispute resolution process
including specific definitions related to the patient-provider dispute resolution process. HHS is also
codifying provisions related to: eligibility for the federal patient-provider dispute resolution process;
selection of an SDR entity; fees associated with this section; certification of SDR entities; and deferral to
state patient-provider dispute resolution processes.
The information collections in the October 2021 interim final rules the advance the legislative goals
of the No Surprises Act.

2. Information Users
HHS will request information from uninsured (or self-pay) individuals in order to initiate patientprovider dispute resolution process. This information will be used to help determine eligibility for the
patient-provider dispute resolution process and is necessary for determining which provider or facility
should be contacted for dispute resolution. Providers and facilities are required to submit information to
SDR entities to inform the SDR entity’s payment determinations.

3. Use of Information Technology
HHS does not restrict the use of electronic technology to process all information collected by
HHS. For the patient-provider dispute resolution process, including the selection of the SDR entity, the
process will be administered through the same HHS-owned portal system. In the case of the patientprovider dispute resolution initiation notification, the individual may request dispute resolution through
the HHS-owned portal, electronically, or on paper.

4. Duplication of Efforts
There is no duplication of efforts for the information collection requirements.

5. Burden on Small Businesses
Providers and facilities incurring burden related to these requirements include providers of air
ambulance services, rural health centers, federally qualified health centers, laboratories, and imaging
centers, many of which may be small businesses. The Departments have tried to minimize the burden on
all respondents.
6. Less Frequent Collection
This information collection is required to fulfill the statutory requirements in the CAA. Uninsured
(or self-pay) individuals will not be able to obtain a good faith estimate, nor will they be able to initiate
the patient-provider dispute resolution process, if this collection is conducted less frequently.

3

Additionally, if this collection is not conducted SDR entities will not be able to submit the required
materials and obtain the required certification.

7. Special Circumstances
There are no special circumstances.

.

8. Federal Register/Outside Consultation
A 60-day FR notice published in the Federal Register on May 2, 2023 (88 FR 27517). A response to
comment document was submitted in response to the single comment received. A 30-day notice published in
the Federal Register on August 17, 2023 (88 FR 56023). No outside consultation was sought.
9. Payments/Gifts to Respondents
There is no payment/gift to respondents.

10. Confidentiality
All information collected under this initiative will be maintained in strict accordance with statutes
and regulations governing confidentiality requirements.

11. Sensitive Questions
There are no sensitive questions associated with these information collections.

12. Burden Estimates (Hours & Wages)
To derive average costs, we are using data from the U.S. Bureau of Labor Statistics’ May 2021 National
Occupational
Employment
and
Wage
Estimates
for
all
salary
estimates
(https://www.bls.gov/oes/current/oes_nat.htm). In this regard, the Table 1 below presents BLS’ mean
hourly wage, our estimated cost of fringe benefits and overhead (calculated at 100 percent of salary), and
our adjusted hourly wage.

4

Table 1. Wage Estimates

Occupational
Code

Hourly Total
Compensation
($/hr)

Fringe
Benefits and
Overhead Cost
($/hr)

Total Hourly
Labor Costs
($/hr)

Secretaries and
Administrative Assistants,
Except Legal, Medical, and
Executive

43-6014

$32.15

$32.15

$64.30

Lawyer

23-1011

$71.17

$71.17

$142.34

General and Operations
Manager

11-1021

$55.41

$55.41

$110.82

All occupations

00-0000

$28.01

$28.01

$56.02

Occupation Title

Collection of Information Requirements and Associated Burden Estimates
Patient-Provider Dispute Resolution Process (45 CFR 149.620)
The October 2021 interim final rules enable uninsured (or self-pay) individuals to initiate a
patient-provider dispute resolution process if their final billed charges are at least $400 more than the
expected charges in the good faith estimate supplied by the provider or facility. HHS does not have data
on how many claims will likely result in patient-provider dispute resolution. For the estimates in this
section, HHS relied on the experience of New York State. In 2015-2018 New York state had 1,486
disputes involving surprise bills submitted to IDR, 31% of these disputes (457 in all) were found
ineligible for IDR for various reasons including 8% (approximately 36 cases) due to being enrolled with
self-insured plans. 5 For purposes of this analysis, HHS assumes that going forward, New York State will
continue to see 40 IDRs each year involving surprise bills for individuals enrolled with self-insured
plans. Accordingly, the Departments estimate that there will be 26,659 claims that result in patientprovider dispute resolution each year. 6
HHS estimates that it will take an average of two hours for an uninsured (or self-pay) individual
or, if they use an authorized representative, one hour for their authorized representative to write, prepare,
and send the notice to initiate the patient-provider dispute resolution to the Secretary. HHS assumes that
uninsured (or self-pay) individuals will self-represent in 90% of the cases, while the remaining 10% will
5

See https://www.dfs.ny.gov/system/files/documents/2019/09/dfs_oon_idr.pdf
The number is estimated as follows: 51,744,200 nonemergency elective procedures (surgical and non-surgical)
performed annually x 9.2% uninsured rate = 4,760,466. HHS assumes that some uninsured individuals will forego
elective procedures because of costs. Therefore, a 30% decrease adjustment was included resulting in 3,332,326.
HHS assumes that 10% of uninsured (or self-pay) individuals who undergo a nonemergency elective procedure will
receive a billed charge that is at least $400 greater than the total amount received in the good faith estimate,
therefore 3,332,326 x 10% = 333,233. HHS assumes that 8% will engage the provider-patient dispute resolution
process, therefore 333,233 x 8% = 26,659.
6

5

be represented by the uninsured (or self-pay) individual’s authorized representative, as allowed by these
interim final rules.
HHS assumes the authorized representative will be a lawyer. Additionally, HHS assumes that a
small percentage of uninsured (or self-pay) individuals or their authorized representatives will be asked to
resubmit or send additional materials to complete the initiation process. This results in an annual
equivalent cost estimate of $3,355,369. 7 The patient-provider dispute resolution initiation notice must be
submitted to the Secretary of HHS within 120 calendar days of receiving billed charges substantially in
excess of the good faith estimate. This also includes an extenuating circumstance request when the
uninsured (or self-pay) individual fails to initiate a patient provider dispute resolution within 120 calendar
days. HHS assumes for uninsured (or self-pay) individuals that 8,973 (34 percent) of initiation notices,
including those that need to be resubmitted with additional materials, will be sent electronically and
17,419 (66 percent) of the initiation notices, including those that need to be resubmitted with additional
materials, will be mailed with an associated printing and materials and postage costs of $13,587.8, 9
To facilitate communication between parties and compliance with this notice requirement, HHS
is concurrently issuing a model notice that the parties may use to satisfy the patient-provider dispute
resolution initiation notice requirement. HHS will consider timely use of the model notice in accordance
with the accompanying instructions to satisfy the notice requirement.
These interim final rules require the SDR entity to attest to the Secretary of HHS whether a
conflict of interest exists with the uninsured (or self-pay) individual, provider, or facility. HHS assumes
that it will take an average of one hour for a general and operations manager and one hour for a lawyer to
determine whether a conflict of interest exists. HHS assumes all communication will be done
electronically. This results in annual equivalent cost estimate of $6,748,992 10 as shown in Table 2.
7

The burden is estimated as follows: 26,659 x 90% = 23,993 uninsured (or self-pay) individuals will self-represent.
23,993 x 2 hours = 47,986 hours. A labor rate of $56.02 is used for uninsured (or self-pay) individuals (all
occupations). The labor rate is applied in the following calculation: 23,993 claims x 2 hours x $56.02= $2,688,176.
HHS assumes that uninsured (or self-pay) individual will appoint an authorized representative in 10% of cases.
26,659 x 10% = 2,666 claims represented by an authorized representative. Therefore, the burden estimate is
estimated as follows: 2,666 claims represented by lawyers x 1 hour = 2,666 hours. A labor rate of $142.34 is used
for a lawyer. The labor rates are applied in the following calculation: 2,666 claims x 1 hour x $142.34= $379,478.
HHS assumes approximately 15% of uninsured (or self-pay) individuals (10% who self-represent + 5% who
appoints an authorized representative) will need to resubmit or submit additional materials to initiate IDR, either
themselves or through their authorized representative. Therefore, the burden estimate is calculated as follows:
23,993 claims x 10% = 2,399 resubmitted claims by individual x 2 hours x $56.02 (labor rate) = $268,784. 2,666
claims x 5% = 133 resubmitted claims by authorized representative x 1 hour x $142.34 (labor rate) = $18,931. The
total annual respondent time cost estimates are added as follows: $2,688,176 + $379,478+ $268,784+ $18,931=
$3,355,369. The total burden hours are 55,584.
8
HHS assumes that the average initiation notice sent via mail by uninsured (or self-pay) individuals will be three
pages in length and printed on 8.5” x 11” sized paper. HHS assumes a $0.05 cost in printing and materials cost per
page and $0.63 in postage cost. Therefore, $0.05 cost per page x 3 pages x 17,419 mailed initiation notices
(inclusive of notices that needed to be resubmitted) = $2,613 in printing and material costs. The postage costs are
calculated as $0.63 cost per postage x 17,419 mailed initiation notices = $10,974 in postage cost. The total printing
and materials and postage costs are therefore $2,613 + $10,974 = $13,587.
9
According to data from the National Telecommunications and Information Agency, 34 percent of households in
the United States accessed health records or health insurance online. https://www.ntia.doc.gov/blog/2020/morehalf- american-households-used-internet-health-related-activities-2019-ntia-data-show.
10
The burden is estimated as follows: 26,659 claims x 1 hour = 26,659 hours. A labor rate of $110.82 is used for a
general and operations manager. The labor rate is applied in the following calculation: 26,659 claims x 1 hour
x$110.82= $2,954,350. The burden for legal review is estimated as follows: 26,659 claims x 1 hour = 26,659 hours.
A labor rate of $142.34 is used for a lawyer. The labor rates are applied in the following calculation: 26,659 claims
x1 hour x $142.34= $3,794,642. The total annual response time cost estimates are added as follows: $2,954,350 +
$3,794,642= $6,748,992. The total burden hours are 53,317.

6

Table 2. Estimated Annual Cost and Hour Burden Related to SDRE Attestation of Conflict of
Interest with a Patient-Provider Dispute Resolution Initiation Notice
Requirement/Notice Estimated Number Estimated Number
of Respondents of Responses (per
Respondent)
SDRE Attestation of
Conflict of Interest
with a PPDR
Initiation Notice

26,659

1

Total
Burden per
Responses
Response
(All
(Hours)
Respondents)

26,659

2

Total Annual Total Estimated
Burden (Hours)
Cost

53,318

$6,748,992

These interim final rules allow uninsured (or self-pay) individuals to attest to having a conflict of
interest with the SDRE that is assigned to their dispute resolution request. In the event of a conflict of
interest with the SDRE, uninsured (or self-pay) individuals may notify HHS to initiate further review by
HHS. HHS estimates that it will take one hour for an uninsured (or self-pay) to write, prepare and send
the notice to HHS. HHS estimates that approximately 66 percent of uninsured (or self-pay) individuals
will send a note in the mail that is one page in length.11 HHS assumes that each uninsured (or self-pay)
individual will incur a printing and materials cost of $0.05 per page and a postage cost of $0.63 per
mailing. Therefore, the annual equivalent cost estimate is $1,504,205 12 for all uninsured (or self-pay)
individuals as shown in Table 3.
Table 3. Estimated Annual Cost and Hour Burden related to Patients Attestation of Conflict of
Interest with SRDE Notice
Estimated
Number of
Total
Burden
Total
Responses
Responses
per
Annual
Requirement/Notice
Estimated
(per
(All
Response Burden
Number of
Respondents Respondent) Respondents) (Hours) (Hours)
Patients Attestation of Conflict of
Interest with SRDE Notice

26,659

1

26,659

1

26,659

Total
Estimated
Cost
$1,504,205

HHS requires that the uninsured (or self-pay) individuals notify the SDRE if a conflict of interest
is determined. To facilitate receipt and review of the notification of conflict of interest, the SDRE must in
turn, submit the notification of conflict of interest notice to the Secretary of HHS on behalf of uninsured
(or self-pay) individuals. HHS estimates that it will take a clerical worker 30 minutes to send these notices
to HHS. HHS assumes that each SDRE will submit these notices to HHS via email correspondence with
no associated printing and mailing costs. Therefore, the annual equivalent cost estimate is $857,087 13 as

HHS assumes that the good faith estimate will be printed in 8.5” x 11” letter sized paper.
The burden is estimated as follows: 26,659 claims x 1 hour = 26,659 hours. A labor rate of $56.02 is used for
uninsured (or self-pay) individuals (all occupations). The labor rate is applied in the following calculation: 26,659
(notification letters) x 1 hour x $56.02 =$1,493,437. HHS assumes a $0.05 cost in printing and materials cost per
page and $0.63 in postage cost. Therefore, the printing and material costs are calculated as $0.05 cost per page x 1
page x 15,835 (66% of notification letters) = $792. The postage costs are calculated as $0.63 cost per postage x
15,835 mailed notification letters = $9,976 in postage cost. The total printing and materials and postage costs are
therefore $792 + $9,976 = $10,768. The total annual respondent time cost estimates are added as follows:
$1,493,437+ $10,768= $1,504,205. The total burden hours are 26,659.
11

12

13

The burden is estimated as follows: 26,659 claims x 0.5 hour = 13,329 hours. A labor rate of $64.30 is used for a

7

shown in Table 4.
Table 4. Estimated Annual Cost and Hour Burden related to SDRE Attestation of Conflict of
Interest with HHS Notice (When the SDRE Submit the Notification of Conflict of Interest Notice to
HHS on Behalf of Patients)
Estimated
Number of
Total
Burden
Total
Responses
Responses
per
Annual
Requirement/Notice
Estimated
(per
(All
Response Burden
Number of
Respondents Respondent) Respondents) (Hours) (Hours)
SDRE Attestation of Conflict of
Interest with HHS Notice (When the
SDRE Submit the Notification of
Conflict of Interest Notice to HHS on
Behalf of Patients)
26,659
1
26,659
0.5
13,329

Total
Estimated
Cost

$857,087

These interim final rules allow the provider to attest to having a conflict of interest with the
SDRE. If a provider or facility has a conflict of interest with the SDRE, they can notify HHS and a new
SDRE without a conflict of interest will be assigned to their case. HHS estimates that it will take a clerical
worker 30 minutes to send the notification letters. HHS assumes that each provider or facility will receive
the notification via email correspondence with no associated printing and mailing costs. Therefore, the
annual equivalent cost estimate is $857,087 14 for all providers and facilities as shown in Table 5.
Table 5: Estimated Annual Cost and Hour Burden Related to Providers/ Facilities Attestation of
Conflict of Interest with SRDE Notice
Estimated
Number of
Total
Burden
Total
Responses
Responses
per
Annual
Requirement/Notice
Estimated
(per
(All
Response Burden
Number of
Respondents Respondent) Respondents) (Hours) (Hours)
Providers/ Facilities Attestation of
Conflict of Interest with SRDE Notice

26,659

1

26,659

0.5

13,329

Total
Estimated
Cost
$857,087

HHS requires that the provider or facility notify the HHS if a conflict of interest is determined.
To facilitate receipt and review of the notification of conflict of interest, HHS estimates that it will take a
clerical worker 30 minutes to notify HHS of each conflict of interest. HHS assumes that each SDRE
entity send notices to HHS via email correspondence with no associated printing and mailing costs.
Therefore, the annual equivalent cost estimate is $857,087 15 as shown in Table 6.

clerical worker. The labor rate is applied in the following calculation: 26,659 (claims) x 0.5 hours x $64.30
=$857,087.
14
The burden is estimated as follows: 26,659 providers/facilities x 0.5 hour = 13,329 hours. A labor rate of $64.30 is used
for a clerical worker. The labor rate is applied in the following calculation: 26,659 (notification letters) x 0.5 hours x
$64.30 =$857,087.
15
The burden is estimated as follows: 26,659 claims x 0.5 hour = 13,329 hours. A labor rate of $64.30 is used for a clerical
worker. The labor rate is applied in the following calculation: 26,659 (claims) x 0.5 hours x $64.30 =$857,087.

8

Table 6. Estimated Annual Cost and Hour Burden Related to SDRE Attestation of Conflict of
Interest with HHS Notice (When the SDRE Submit the Notification of Conflict of Interest Notice to
HHS on Behalf of Providers/Facilities)
Estimated
Number of
Total
Burden
Total
Requirement/Notice
Responses
Responses
per
Annual
Estimated
Total
(per
(All
Response Burden
Number of
Estimated
Respondents Respondent) Respondents) (Hours) (Hours)
Cost
SDRE Attestation of Conflict of Interest
with HHS Notice (When the SDRE
Submit the Notification of Conflict of
Interest Notice to HHS on Behalf of
Providers/Facilities)

26,659

1

26,659

0.5

13,329

HHS notifies both uninsured (or self-pay) individuals and providers or facilities about the
outcome of the conflict of interest via email correspondence with no associated printing and mailing costs
while requiring no further information from the parties. 16
These interim final rules also require the SDR entity to review eligibility and completeness of the
initiation notice and notify uninsured (or self-pay) individuals, providers or facilities of the SDR entity’s
selection to conduct dispute resolution. Providers and facilities are thereafter required to furnish
additional information to the SDR entity within 10 business days after receiving notification of SDR
entity selection. This information must include: (1) a copy of the good faith estimate provided to the
uninsured (or self-pay) individual for the items or services under dispute; (2) a copy of the bill provided to
the uninsured (or self-pay) individual for items or services under dispute; and (3) if available,
documentation providing evidence to demonstrate the difference between the good faith estimate and the
billed charge reflects a medically necessary 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. HHS estimates that it will take an average of one hour for a general and operations manager to
address these requirements and send to the SDR entity. This results in an annual equivalent cost estimate
of $2,954,350. 17
These interim final rules require the SDR entity to assess the information provided by the
provider or facility according to the standards described in 45 CFR 149.620(f) and discussed in section
VI.B.7 of the preamble. The SDR entity must make a determination within 30 days after receipt of
information from the provider or facility. HHS estimates that it will take an average of two hours for a
general and operations manager and two hours for a lawyer to assess the merits of the submitted
information and determine a prevailing party. This results in an annual equivalent cost estimate of
$13,497,985 18 as shown in Table 7.
16

The labor cost associated to email the notification letters is accounted for annual ongoing costs associated with
implementation and the administration of the PPDR program in the federal government cost under section 14.
17
The burden is estimated as follows: 26,659 claims x 1 hour = 26,659 hours. A labor rate of $110.82 is used for a
general and operations manager. The labor rate is applied in the following calculation: 26,659 claims x 1 hour x
$110.82= $2,954,350. Total burden hours are 26,659 hours.
18
The burden is estimated as follows: 26,659 claims x 2 hours = 53,317 hours. A labor rate of $110.82 is used for a
general and operations manager. The labor rate is applied in the following calculation: 26,659 claims x 2 hours x
$110.82 = $5,908,701. The burden for legal review is estimated as follows: 26,659 claims x 2 hours = 53,317 hours.
A labor rate of $142.34 is used for a lawyer. The labor rates are applied in the following calculation: 53,317 x
$142.34 = $7,589,284. The total annual respond time cost estimates are calculated as follows: $5,908,701+

9

$857,087

Table 7. Estimated Annual Burden to Assess the Submitted Information and Determine a
Prevailing Party
Estimated
Number of
Total
Burden
Total
Requirement/Notice
Responses
Responses
per
Annual
Estimated
(per
(All
Response Burden
Number of
Respondents Respondent) Respondents) (Hours) (Hours)
Assessment of the Submitted
Information and Determine a
Prevailing Party
26,659
1
26,659
4
106,634
HHS estimates that it will take an average of 30 minutes for an SDR entity’s general and
operations manager to notify parties of the SDR entity’s determination. This results in an annual
equivalent cost estimate of $1,477,175. 19
The SDR entity must also submit the administrative fee to the Secretary of HHS on behalf of
disputing parties. This burden includes time to review instructions, search existing data resources, gather
data needed, and complete and review the information collection. HHS estimates that the time required to
complete and submit this information collection is estimated to average a clerical worker 1.5 hours per
month (or 18 hours annually), with a total annual cost of $3,472 20, as shown in Table 8.
Table 8. Estimated Annual Burden and Cost Related to SDR Entity Submission of the
Administrative fee to HHS
Requirement/Notice
SDRE Submission of the Administrative
fee to HHS

Estimated
Number of
Respondents

Total Annual
Burden (1.5
hours x 12
months)

Annual Cost
Per IDR
entity

Annual
Cost for
all
Responses

3

18

1,157

$3,472

The total annual burden associated with the patient-provider dispute resolution process for
uninsured (or self-pay) individuals and providers and facilities is 322,189 hours with an equivalent cost of
$32,112,809 as shown in Table 9 below. HHS invites comments on the assumptions and calculations
made in these ICRs.

$7,589,284 = $13,497,985. The total annual burden hours are 106,634 hours.
19
The burden is estimated as follows: 26,659 claims x 0.5 hour = 13,330 hours. A labor rate of $110.82 is used for a
general and operations manager. The labor rate is applied in the following calculation: 26,659 claims x 0.5 hour x
$110.82 = $1,477,175. Total burden hours are 13,330 hours.
20
The burden is estimated as follows: A labor rate of $64.30 is used for a clerical worker. The labor rate is applied
in the following calculation: 3 annual responses x 18 hours x $64.30= $3,472.

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Total
Estimated
Cost
$13,497,985

Table 9: Summary of Annual Burden Estimates

Requirement/Notice

Estimated
Number of
Respondents

Estimated
Number of
Responses
(per
Respondent)

Total Responses
(All
Respondents)

Burden
per
Response
(Hours)

Total
Annual
Burden
(Hours)

Total
Estimated
Cost

Uninsured or Self-Pay
Individuals and Authorized
Representatives to Write,
Prepare and Send the
Initiation Notice for the
PPDR to HHS, including
Resubmission Costs Notice

26,659

1.15

30,658

1.8

55,584

$3,355,369

SDRE Attestation of
Conflict of Interest with a
PPDR Initiation Notice

26,659

1

26,659

2

53,318

$6,748,992

26,659

1

26,659

1

26,659

$1,504,205

26,659

1

26,659

0.5

13,329

$857,087

26,659

1

26,659

0.5

13,329

$857,087

26,659

1

26,659

0.5

13,329

$857,087

26,659

1

26,659

1

26,659

$2,954,350

26,659

1

26,659

4

106,634

$13,497,985

Patients Attestation of
Conflict of Interest with
SRDE Notice
SDRE Attestation of
Conflict of Interest with
HHS Notice (When the
SDRE Submit the
Notification of Conflict of
Interest Notice to HHS on
Behalf of Patients)
Providers/ Facilities
Attestation of Conflict of
Interest with SRDE Notice
SDRE Attestation of
Conflict of Interest with
HHS Notice (When the
SDRE Submit the
Notification of Conflict of
Interest Notice to HHS on
Behalf of
Providers/Facilities)
Uninsured or Self-Pay
Individuals and Providers
or Facilities to Furnish
Additional Information to
Selected SDR Entities
Notice
Assessment of the
Submitted Information and
Determine a Prevailing
Party Notice

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SDRE Notification to the
Parties of the SDRE’s
Determination Notice
SDRE Submission of the
Administrative fee to HHS
Total

26,659

1

26,659

0.5

3

6

3

13,330

$1,477,175

18
$3,472
322,189 $32,112,809

Information Collection Instruments and Instruction/Guidance Documents
Appendix 1: Ineligible for Patient-Provider Dispute Resolution or Additional Information Needed
Appendix 2: Patient-Provider Dispute Resolution Form
Appendix 3: Patient-Provider Selected Dispute Resolution (SDR) Entity Certification Application Data
Elements
Appendix 4: Independent Dispute Resolution and Patient-Provider Dispute Resolution Processes; Vendor
Management Data Elements
Appendix 5: Patient-Provider Dispute Resolution Process Data Elements
Appendix 6: Selected Dispute Resolution (SDR) Determination Notice to Parties Provided Under the No
Surprises Act
Appendix 7: Selected Dispute Resolution (SDR) Entity Notification to Health Care Providers and
Facilities and Uninsured (or Self-Pay) Individuals
Appendix 8: Uninsured (or Self-Pay) Individual and Provider or Facility Settle on a Payment Amount
After Initiating Patient- Provider Dispute Resolution
Appendix 9: Selected Dispute Resolution (SDR) Entity Notification to Health Care Provider or Facility
and Uninsured (or Self-Pay) Individual Confirming Receipt of Dispute Settlement and Action
Appendix 10: Standard Notice: Uninsured (or Self-Pay) Individual, Provider or Facility’s Notification to
Secretary of Health and Human Services Requesting Extension
13. Capital Costs
HHS estimates the overall printing, materials and mailing costs for uninsured (or self-pay)
individuals to send initiation notices for dispute resolution to the Secretary of HHS ($13,587) and to attest
conflict of interest with SRDE notice ($11,086) is estimated to be $24,673. 21

21
HHS assumes that notices will be printed in 8.5” x 11” letter sized paper, $0.05 cost in printing and materials cost
per page and $0.63 in postage cost.

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14. Cost to Federal Government
HHS estimates the total annual ongoing costs associated with implementation and the
administration of the PPDR program, including system maintenance, and program support, is estimated
to be $12.6 million, this cost will be offset by the collection of the $25 administrative fee, resulting in a
total anticipated collection of $666,475 and a total approximate annual cost to the federal government of
$12 million.
15. Changes to Burden
This is a new information collection request.
16. Publication/Tabulation Dates
There are no plans to publish the outcome of the information collection.
17. Expiration Date
The expiration date will be displayed on the first page of each instrument (top, right-hand corner).

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