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

Documents and forms in this information collection
Document Name	Document Type
ON Notice Instrument 6.8.26.docx	Other-Notice of Open Negotiation
Notice of IDR Initiation Instrument 6.8.26.docx	Other-Notice of IDR Initiation
IDR Entity Selection Response webform 6.8.26.docx	Other-IDR Entity Selection Response
Notice of Agreement 6.8.26.docx	Other- Notice of Agreement on an Out
APPENDIX 3 - Notice of Offer Data Elements 6.8.26.docx	Other-Notice of Offer Data Elements
IDR_Initiation_Webform 6.8.26.docx	Other-IDR Initiation Webform
IDRE Selection Response Instrument 6.8.26.docx	Other-Selection of Certified IDR Ent
Notice of IDR Initiation Response Instrument 6.8.26.docx	Other-Notice of IDR Initiation Respo
ON Notice Response Instrument 6.8.26.docx	Other-Notice of Open Negotiation Res
Withdrawal Notice 6.8.26.docx	Other-Withdrawal Notice

IC Title:

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 2590

Information Collection Instruments:

table that charts list of instruments
Document Type	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Notice of Open Negotiation	Yes	Yes	Fillable Printable
Other-Notice of IDR Initiation	Yes	Yes	Fillable Printable
Other-IDR Entity Selection Response webform	Yes	Yes	Fillable Printable
Other- Notice of Agreement on an Out-of-Network Rate	Yes	Yes	Fillable Printable
Other-Notice of Offer Data Elements	Yes	Yes	Fillable Printable
Other-IDR Initiation Webform	Yes	Yes	Fillable Printable
Other-Selection of Certified IDR Entity Data Elements	Yes	Yes	Fillable Printable
Other-Notice of IDR Initiation Response	Yes	Yes	Fillable Printable
Other-Notice of Open Negotiation Response	Yes	Yes	Fillable Printable
Other-Withdrawal Notice	Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,600,000

Number of Respondents for Small Entity: 2,288,000

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 95 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5,434,000	2,679,000	2,755,000
Annual IC Time Burden (Hours)	3,537,625	1,846,375	1,691,250
Annual IC Cost Burden (Dollars)	78,892,775	20,384,635	58,508,140

Documents for IC

table that charts IC Documents
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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