OMB control number

Requirements Related to Surprise Billing: Qualifying Payment Amount, Notice and Consent, Disclosure on Patient Protections Against Balance Billing, and State Law Opt-in (CMS-10780)

OMB 0938-1401 · HHS/CMS.

OMB 0938-1401

On December 27, 2020, the Consolidated Appropriations Act, 2021 (Pub. L. 116-260), which included the No Surprises Act, was signed into law. 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” (2021 interim final regulations) issued by the Departments of Health and Humans Services, the Department of Labor, the Department of Treasury, and the Office of Personnel Management, implement provisions of the No Surprises Act that apply to group health plans, health insurance issuers offering group or individual health insurance coverage, and carriers in the Federal Employees Health Benefits (FEHB) Program 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 2021 interim final regulations prohibit nonparticipating providers, emergency facilities, and providers of air ambulance services from balance billing participants, beneficiaries, and enrollees in certain situations unless they satisfy certain notice and consent requirements. The No Surprises Act and the 2021 interim final regulations require group health plans and issuers of health insurance coverage to provide information about qualifying payment amounts to nonparticipating providers and facilities and to provide disclosures on patient protections against balance billing to participants, beneficiaries and enrollees. Self-insured plans opting in to State law are required to provide a disclosure to participants. Certain nonparticipating providers and nonparticipating emergency facilities may are provide participants, beneficiaries, and enrollees with notice and obtain their consent to waive balance billing protections, provided certain requirements are met. In addition, certain providers and facilities are required to provide disclosures on patient protections against balance billing to participants, beneficiaries and enrollees.

The latest form for Requirements Related to Surprise Billing: Qualifying Payment Amount, Notice and Consent, Disclosure on Patient Protections Against Balance Billing, and State Law Opt-in (CMS-10780) expires 2028-12-31 and is listed under ICR 202506-0938-006.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
Document	Type
Form CMS-10780 Standard Notice and Consent	Form and Instruction
Form CMS-10780 Information Related to Qualifying Payment Amount to be Shared with Nonparticipating Providers or Nonparticipating Emergency Facilities	Form and Instruction
Form CMS-10780 Standard Notice and Consent	Form and Instruction
Form CMS-10780 Notice and Consent to be Treated by a Nonparticipating Provider or Nonparticipating Emergency Facility, Retention of Certain Documents, and Notice to Plan or Issuer – Consumer Burden	Form and Instruction
Form CMS-10780 Standard Notice and Consent	Form and Instruction
Form CMS-10780 Notice and Consent to be Treated by a Nonparticipating Provider or Nonparticipating Emergency Facility, Retention of Certain Documents, and Notice to Plan or Issuer - Facilities and Providers	Form and Instruction
CMS-10780.Supporting Statement Part A (30-day).docx	Supporting Statement A
CMS-10780.Supporting Statement Part A (30-day).docx	Supporting Statement A
Disclosure for Self-Insured Plans Opting-in to State Law	Other-Model Notice
Information Related to Qualifying Payment Amount to be Shared with Nonparticipating Providers or Nonparticipating Emergency Facilities	Form and Instruction
Information Related to Qualifying Payment Amount to be Shared with Nonparticipating Providers or Nonparticipating Emergency Facilities	Form and Instruction
Notice and Consent to be Treated by a Nonparticipating Provider or Nonparticipating Emergency Facility, Retention of Certain Documents, and Notice to Plan or Issuer – Consumer Burden	Form and Instruction
Notice and Consent to be Treated by a Nonparticipating Provider or Nonparticipating Emergency Facility, Retention of Certain Documents, and Notice to Plan or Issuer – Consumer Burden	Form and Instruction
Notice and Consent to be Treated by a Nonparticipating Provider or Nonparticipating Emergency Facility, Retention of Certain Documents, and Notice to Plan or Issuer - Facilities and Providers	Form and Instruction
Notice and Consent to be Treated by a Nonparticipating Provider or Nonparticipating Emergency Facility, Retention of Certain Documents, and Notice to Plan or Issuer - Facilities and Providers	Form and Instruction
Plan and Issuer Disclosure on Patient Protections Against Balance Billing	Other-Model Notice
Title: Provider Disclosure on Patient Protections Against Balance Billing – Facility and Provider Agreements	Other-Model Notice
Provider Disclosure on Patient Protections Against Balance Billing - Facilities and Providers	Other-Model Notice
Provider Disclosure on Patient Protections Against Balance Billing - States	Other-Model Notice

All Historical Document Collections

Historical document collections
Reference	Filing	Received	Action
202506-0938-006	Reinstatement without change of a previously approved collection	2025-06-09
202205-1210-001CF	RCF Recertification	2022-05-20	Approved
202203-0938-004	Extension without change of a currently approved collection	2022-03-17	Approved with change
202109-1210-001CF	RCF New	2021-10-06	Approved with change
202108-0938-017	New collection (Request for a new OMB Control Number)	2021-09-09	Approved with change

OMB Details

Provider Disclosure on Patient Protections Against Balance Billing - States

Federal Enterprise Architecture: Health - Health Care Services