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Federal forms, ICRs, and supporting documents

Information Collection

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

IC 252194 under ICR 202606-1545-001CF · OMB 1210-0169.

Documents and Forms
Document Name
Document Type
Other-Notice of Open Negotiation
Other-Notice of IDR Initiation
Other-Notice of Certified IDR Entity
Other- Notice of Agreement on an Out
Other-Payment Settlement Form
Other-Notice of Offer Data Elements
Other-IDR Initiation Webform
Other-IDR Entity Selection Response
Other-Good Faith Estimate Template N
Other-PPDR Data Elements for Patient
Other-Online PPDR Initiation Form
Other-PPDR Dispute Initiation Form
Other-Vendor Management Data Element
Information Collection (IC) Details

View RCF Information Collection (IC)

Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities
 
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 2. Tri-dept - open negotiation period notice 4.20.22 clean.docx Yes Yes Fillable Printable
Other-Notice of IDR Initiation 3. Tri-dept - notice of IDR Initiation 4.20.22.docx Yes Yes Fillable Printable
Other-Notice of Certified IDR Entity Selection 4. Tri-dept - notice of certified IDR entity selection 4.20.22 clean.docx Yes Yes Fillable Printable
Other- Notice of Agreement on an Out-of-Network Rate 5. Tri-dept - notice of agreement of OON rate (data elements) clean 9.28.21.docx Yes Yes Fillable Printable
Other-Payment Settlement Form 10. PPDR Payment Settlement Form Notice.docx Yes Yes Fillable Printable
Other-Notice of Offer Data Elements APPENDIX 3 - Notice of Offer Data Elements FINAL CHANGE 2.23.23.docx Yes Yes Fillable Printable
Other-IDR Initiation Webform IDR_Initiation_Webform.docx Yes Yes Fillable Fileable
Other-IDR Entity Selection Response Webform IDR Entity Selection Response webform.docx Yes Yes Fillable Fileable
Other-Good Faith Estimate Template Notice CMS-10791-Good-Faith-Estimate-Model-Notice.pdf Yes Yes Fillable Printable
Other-PPDR Data Elements for Patients and Providers Appendix-7-Dispute-Resolution-Data-Elements-for-Patients-and-Providers.pdf Yes Yes Fillable Printable
Other-Online PPDR Initiation Form Billing Dispute Initiation Form.pdf Yes Yes Fillable Printable
Other-PPDR Dispute Initiation Form Billing Dispute Initiation Form.pdf Yes Yes Fillable Printable
Other-Vendor Management Data Elements CMS-10791-6.-HHS-Appendix-Vendor-Management-VM-Data-Elements.pdf Yes Yes Fillable Printable

Income Security General Retirement and Disability

 

8,667 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  Approved 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 13,743 0 0 0 0 13,743
Annual IC Time Burden (Hours) 8,383 0 0 -18,691 0 27,074
Annual IC Cost Burden (Dollars) 291,861 0 0 79,748 0 212,113

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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