View RCF  - OIRA Conclusion

202205-1210-001CF 202109-1210-001CF
Active 05/31/2025
DOL/EBSA
0938-1401 202203-0938-004
Requirements Related to Surprise Billing: Qualifying Payment Amount, Notice and Consent, Disclosure on Patient Protections Against Balance Billing, and State Law Opt-in
RCF Recertification
 Approved   05/20/2022
Retrieve Notice of Action (NOA) 05/20/2022
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
DOL will be using the model notice, Provider Disclosure on Patient Protections Against Balance Billing - Facilities and Providers, for ERISA covered plans.
None
 $0
James Butikofer 202 693-8434 [email protected]

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

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

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