View Information Collection Request (ICR) Package

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: 0938-1470	ICR Reference No: 202309-0938-001
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CCIIO - 10853
Title: Patient Provider Dispute Resolution Requirements Related to Surprise Billing: Part II (CMS-10853)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/17/2024
	Date Received in OIRA: 09/11/2023
Terms of Clearance: Approved consistent with the understanding that in the next revision/extension of the package (no later than March 28, 2029), the agency will update the race/ethnicity question in this information collection to be in compliance with the updated SPD 15 (effective as of March 28, 2024).

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2027	36 Months From Approved
Responses	26,659	0	0
Time Burden (Hours)	322,189	0	0
Cost Burden (Dollars)	32,112,898	0	0

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Requirements Related to Surprise Billing; Part II; Patient-Provider Dispute Resolution Process	CMS-10853, CMS-10853, cms-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, cms-10853, CMS-10853, cms-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-10853, CMS-108i53, CMS-10853, CMS-10853, CMS-10853, CMS-10853, cms-10853, CMS-10853, CMS-10853	, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

ICR Summary of Burden

	Total Approved	Change Due to New Statute
Annual Number of Responses	26,659	26,659
Annual Time Burden (Hours)	322,189	322,189
Annual Cost Burden (Dollars)	32,112,898	32,112,898

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: This is a new collection of information.

Annual Cost to Federal Government: $12,600,000

Does this IC contain surveys, censuses, or employ statistical methods? No

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. No

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. No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Jamaa Hill 301 492-4190

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