OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities

IC 248846 under ICR 202606-1210-003 · OMB 1210-0169.

Documents and Forms
Document Name
Document Type
Other-Notice of Open Negotiation
Other-Notice of IDR Initiation
Other-IDR Entity Selection Response
Other- Notice of Agreement on an Out
Other-Notice of Offer Data Elements
Other-IDR Initiation Webform
Other-Selection of Certified IDR Ent
Other-Notice of IDR Initiation Respo
Other-Notice of Open Negotiation Res
Other-Withdrawal Notice
Information Collection (IC) Details

View Information Collection (IC)

Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities
 
Yes Modified
 
Mandatory
 
29 CFR 2590

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Notice of Open Negotiation ON Notice Instrument 6.8.26.docx Yes Yes Fillable Printable
Other-Notice of IDR Initiation Notice of IDR Initiation Instrument 6.8.26.docx Yes Yes Fillable Printable
Other-IDR Entity Selection Response webform IDR Entity Selection Response webform 6.8.26.docx Yes Yes Fillable Printable
Other- Notice of Agreement on an Out-of-Network Rate Notice of Agreement 6.8.26.docx Yes Yes Fillable Printable
Other-Notice of Offer Data Elements APPENDIX 3 - Notice of Offer Data Elements 6.8.26.docx Yes Yes Fillable Printable
Other-IDR Initiation Webform IDR_Initiation_Webform 6.8.26.docx Yes Yes Fillable Printable
Other-Selection of Certified IDR Entity Data Elements IDRE Selection Response Instrument 6.8.26.docx Yes Yes Fillable Printable
Other-Notice of IDR Initiation Response Notice of IDR Initiation Response Instrument 6.8.26.docx Yes Yes Fillable Printable
Other-Notice of Open Negotiation Response ON Notice Response Instrument 6.8.26.docx Yes Yes Fillable Printable
Other-Withdrawal Notice Withdrawal Notice 6.8.26.docx Yes Yes Fillable Printable

Income Security General Retirement and Disability

 

2,600,000 2,288,000
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   95 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 5,434,000 0 0 2,679,000 0 2,755,000
Annual IC Time Burden (Hours) 3,537,625 0 0 1,846,375 0 1,691,250
Annual IC Cost Burden (Dollars) 78,892,775 0 0 20,384,635 0 58,508,140

Title Document Date Uploaded
No associated records found
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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