View Information Collection (IC)
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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Federal IDR Process for Air Ambulance Services
Agency IC Tracking Number:
Is this a Common Form?
Yes
IC Status:
Modified
Obligation to Respond:
Mandatory
CFR Citation:
29 CFR 2590
Information Collection Instruments:
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-Good Faith Estimate Template Notice
CMS-10791 - Good Faith Estimate Template Notice.pdf
Yes
Yes
Fillable Printable
Other- PPDR Data Elements for Patients and Providers
7. Appendix-HHS PPDR Data Elements for Patients and Providers.docx
Yes
Yes
Fillable Printable
Other-Vendor Management Data Elements
6. Appendix-HHS Vendor Management (VM) Data Elements.docx
Yes
Yes
Fillable Printable
Other-Payment Settlement Form Notice
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-PPDR Dispute Initiation Form
4. PPDR Dispute Initiation Form.docx
Yes
Yes
Fillable Printable
Other-Online PPDR Initiation Form
14. Online PPDR Initiation Form.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
Federal Enterprise Architecture Business Reference Module
Line of Business:
Income Security
Subfunction:
General Retirement and Disability
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
4,968
Number of Respondents for Small Entity:
255
Affected Public:
Private Sector
Private Sector:
Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
95 %
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
7,879
0
0
0
0
7,879
Annual IC Time Burden (Hours)
13,671
0
0
0
0
13,671
Annual IC Cost Burden (Dollars)
121,598
0
0
0
0
121,598
Documents for IC
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.