Complaints Submission Process under the No Surprises Act (CMS-10779)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10779 Provider Complaint Form - No Surprises Help Desk	Form and Instruction	Modified	Available
Form CMS-10779 Consumer Complaint Form - No Surprises Help Desk	Form and Instruction	Modified	Available
CMS-10779 - Supporting Statement.docx	Supporting Statement A	Uploaded 2026-03-04	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
249022	Complaints Related to Surprise Billing	Form and Instruction	Modified	Provider Complaint Form - No Surprises Help Desk
249022	Complaints Related to Surprise Billing	Form and Instruction	Modified	Consumer Complaint Form - No Surprises Help Desk
249022	Complaints Related to Surprise Billing	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1406	ICR Reference No: 202603-0938-002
Status: Received in OIRA	Previous ICR Reference No: 202206-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No: CCIIO
Title: Complaints Submission Process under the No Surprises Act (CMS-10779)
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  Yes
Type of Review Request: Regular	Date Submitted to OIRA: 03/04/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	39,000	0
Time Burden (Hours)	19,500	0
Cost Burden (Dollars)	1,055,730	0

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Abstract: Enacted on December 27, 2020, the No Surprises Act, which was enacted as part of the Consolidated Appropriations Act (CAA), amended the Employee Retirement Income Security Act of 1974 (ERISA), the Public Health Service Act (PHS Act), and the Internal Revenue Code of 1986 (Code). The No Surprise Act implements provisions that protect individuals from surprise medical bills for emergency services, air ambulance services furnished by nonparticipating providers, and non-emergency services furnished by nonparticipating providers at participating facilities in certain circumstances. Additionally, the No Surprises Act sets forth a complaints processes with respect to potential violations of balance billing requirements set forth in the No Surprises Act. 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 medical bills arise most frequently. The 2021 interim final regulations “Requirements Related to Surprise Billing; Part I” (86 FR 36872, 2021 interim final regulations) issued by the Departments of Health and Humans Services (HHS), Department of Labor (DOL), the Department of Treasury (collectively, the Departments), implement provisions of the No Surprises Act that apply to group health plans, health insurance issuers offering group or individual health insurance coverage that provide protections against balance billing and out-of-network cost sharing with respect to emergency services, non-emergency services furnished by nonparticipating providers at certain participating health care facilities, and air ambulance services furnished by nonparticipating providers of air ambulance services. The No Surprises Act and the 2021 interim final regulations directs the Departments of Labor, Health and Human Services, and the Department of Treasury (collectively, “the Departments”) to establish a process to receive complaints regarding violations of the application of qualifying payment amount (QPA) requirements by group health plans and health insurance issuers offering group or individual health coverage. The No Surprises Act also directs HHS to establish a process to receive consumer complaints regarding violations by health care providers, facilities, and providers of air ambulance services regarding balance billing requirements and to respond to such complaints within 60 days.

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Authorizing Statute(s): PL: Pub.L. 120 - 260 No Surprises Act - 102, 104 Name of Law: Consolidated Appropriations Act, 2021
  

Citations for New Statutory Requirements: PL: Pub.L. 120 - 260 102, 104 - No Surprises Act Name of Law: Consolidated Appropriations Act, 2021

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 46212	09/25/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 4923	02/03/2026
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Complaints Related to Surprise Billing	CMS-10779, CMS-10779	Consumer Complaint Form - No Surprises Help Desk ,   Provider Complaint Form - No Surprises Help Desk

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ICR Summary of Burden

table that charts list of burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	39,000	0	0	0	0	39,000
Annual Time Burden (Hours)	19,500	0	0	0	0	19,500
Annual Cost Burden (Dollars)	1,055,730	0	0	0	0	1,055,730

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $4,800,000,090

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  Yes

Description/Changes for Common Form Usage:  The information collection is necessary to establish a process to receive complaints regarding violations of the application of qualifying payment amount requirements by group health plans and health insurance issuers offering group or individual health coverage as required by the No Surprises Act (enacted on December 27, 2020). The No Surprises Act also directs HHS to establish a process to receive consumer complaints regarding violations by health care providers, facilities, and providers of air ambulance services regarding balance billing requirements and to respond to such complaints within 60 days. The data collection will assist CMS in requesting information from non-federal governmental plans and issuers, health care providers, facilities, providers of air ambulance services, and individuals to review and process a complaint for potential violations of balance billing requirements.

Approved RCFs using this ICR

table that charts list of RCF

Agency/Sub Agency	RCF ID	RCF Title	RCF Status	IC Title

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/04/2026

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