View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities and Providers of 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			ON Notice Instrument 10.23.23_clean.docx		Yes	Yes	Fillable Printable
Other-Notice of IDR Initiation			Notice of IDR Initiation Instrument 10.23.23_clean.docx		Yes	Yes	Fillable Printable
Other-Notice of Certified IDR Entity Selection			IDRE Selection Response Instrument 10.23.23_clean.docx		Yes	Yes	Fillable Printable
Other- Notice of Agreement on an Out-of-Network Rate			Notice of Agreement 10.23.23_clean.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-Notice of IDR Initiation Response			Notice of IDR Initiation Response Instrument 10.23.23_clean.docx		Yes	Yes	Fillable Printable
Other-Notice of Open Negotiation Response			ON Notice Response Instrument 10.23.23_clean.docx		Yes	Yes	Fillable Printable
Other-Withdrawal Notice			Withdrawal Notice 10.23.23_clean.docx		Yes	Yes	Fillable Printable

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: 420,000	Number of Respondents for Small Entity: 369,600

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 95 %

	Requested	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	1,085,700	0	0	1,058,051	0	27,649
Annual IC Time Burden (Hours)	1,568,963	0	0	1,514,446	0	54,517
Annual IC Cost Burden (Dollars)	11,141,820	0	0	10,715,078	0	426,742

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.