View Information Collection Request (ICR) Package
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Brief and OIRA conclusion
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Legal Statutes
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FR Notices/Comments
IC List
Burden
Misc.
Common Form Info.
Certification
View Information Collection (IC) List
View Supporting Statement and Other Documents
Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
1210-0169
ICR Reference No:
202110-0938-001CF
Status:
Active
Previous ICR Reference No:
Agency/Subagency:
HHS/CMS
Agency Tracking No:
Title:
Requirements Related to No Surprise Billing Act, Part II (Independent Dispute Resolution Process) (CMS-10791)
Type of Information Collection:
RCF New
Common Form ICR:
Type of Review Request:
OIRA Conclusion Action:
Approved without change
Conclusion Date:
10/26/2021
Retrieve Notice of Action (NOA)
Date Received in OIRA:
10/21/2021
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
04/30/2022
Responses
8,853,972
0
0
Time Burden (Hours)
12,894,074
0
0
Cost Burden (Dollars)
33,476,812
0
0
Abstract:
Authorizing Statute(s):
PL:
Pub.L. 116 - 260 103 and 105
Name of Law: Consolidated Appropriations Act, 2021
Citations for New Statutory Requirements:
PL: Pub.L. 105 - 105 No Surprises Act Name of Law: Consolidated Appropriations Act, 2021
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Federal Register Notices & Comments
Did the Agency receive public comments on this ICR?
Number of Information Collection (IC) in this ICR:
4
IC Title
Form No.
Form Name
Federal IDR Process for Air Ambulance Services
Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities
IDR Entity Certification and IDR Entity Monthly Reporting
Request of Extension of Time Periods for Extenuating Circumstances
ICR Summary of Burden
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
8,853,972
0
0
3,486,717
5,367,255
0
Annual Time Burden (Hours)
12,894,074
0
0
1,869,193
11,024,881
0
Annual Cost Burden (Dollars)
33,476,812
0
0
31,044,714
2,432,098
0
Burden increases because of Program Change due to Agency Discretion:
Yes
Burden Increase Due to:
Miscellaneous Actions
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
This is a new ICR associated with the common form.
Annual Cost to Federal Government:
$6,000,000
Does this IC contain surveys, censuses, or employ statistical methods?
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
Uncollected
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
Uncollected
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
Uncollected
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Jamaa Hill 301 492-4190
Common Form ICR:
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
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