Information Collection

Federal IDR Process for Air Ambulance Services

IC 248850 under ICR 202606-1210-003 · OMB 1210-0169.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
2. Tri-dept - open negotiation period notice 4.20.22 clean.docx	Other-Notice of Open Negotiation
3. Tri-dept - notice of IDR Initiation 4.20.22.docx	Other-Notice of IDR Initiation
4. Tri-dept - notice of certified IDR entity selection 4.20.22 clean.docx	Other-Notice of Certified IDR Entity
5. Tri-dept - notice of agreement of OON rate (data elements) clean 9.28.21.docx	Other-Notice of Agreement on an Out-
APPENDIX 3 - Notice of Offer Data Elements FINAL CHANGE 2.23.23.docx	Other-Notice of Offer Data Elements
IDR_Initiation_Webform.docx	Other-IDR Initiation Webform
IDR Entity Selection Response webform.docx	Other-IDR Entity Selection Response
CMS-10791-Good-Faith-Estimate-Model-Notice.pdf	Other-Good Faith Estimate Template N
CMS-10791-Good-Faith-Estimate-Model-Notice.pdf	Other- PPDR Data Elements for Patien
CMS-10791-6.-HHS-Appendix-Vendor-Management-VM-Data-Elements.pdf	Other-Vendor Management Data Element
Billing Dispute Initiation Form.pdf	Other-PPDR Dispute Initiation Form
Billing Dispute Initiation Form.pdf	Other-Online PPDR Initiation Form
10. PPDR Payment Settlement Form Notice.docx	Other-Payment Settlement Form Notice

IC Title:

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: Unchanged

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-Notice of Certified IDR Entity Selection	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 Fileable
Other-IDR Entity Selection Response Webform	Yes	Yes	Fillable Printable
Other-Good Faith Estimate Template Notice	Yes	Yes	Fillable Printable
Other- PPDR Data Elements for Patients and Providers	Yes	Yes	Fillable Printable
Other-Vendor Management Data Elements	Yes	Yes	Fillable Printable
Other-PPDR Dispute Initiation Form	Yes	Yes	Fillable Printable
Other-Online PPDR Initiation Form	Yes	Yes	Fillable Printable
Other-Payment Settlement Form 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: 0

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 95 %

table that charts list of burden
	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	0	0	0	0	0	0
Annual IC Time Burden (Hours)	0	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

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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