View RCF - OIRA Conclusion

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

Type of RCF: RCF Recertification
OIRA Conclusion Action: Approved	Conclusion Date: 05/20/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/20/2022
Terms of Clearance: Approved consistent with the understanding that the agency will review and consider all comments received from the rule in addition to those received during the 60 and 30 FRN periods as this package transitions from an emergency to a standard collection

Description of Agency Usage: DOL will be using the model notice, Provider Disclosure on Patient Protections Against Balance Billing - Facilities and Providers, for ERISA covered plans.

Authorizing Statute(s): None

Annual Cost to Federal Government: $0
Agency Contact: James Butikofer 202 693-8434 [email protected]

Common Form Information Collections (IC) in this RCF:

IC Title	Status	Responses	Hours	Dollars	Document Type	Form No.	Form Name
Information Related to Qualifying Payment Amount to be Shared with Nonparticipating Providers or Nonparticipating Emergency Facilities		1,900,692	361,131	0	Form and Instruction	CMS-10780	Standard Notice and Consent
Plan and Issuer Disclosure on Patient Protections Against Balance Billing		8,466,479	84,665	0	Other

RCF Summary of Burden:

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	10,367,171	10,367,171	0
Annual Time Burden (Hours)	445,796	463,193	-17,397
Annual Cost Burden (Dollars)	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

202205-1210-001CF