Crosswalk

Crosswalk of Changes to Information Collection Request 1210-0169 No Surprises Act: (IDR) Process

The Department has removed language from the following documents to be consistent with the Texas federal court ruling on the Interim Final Rule, Requirements Related to Surprise Billing; Part II:

• Supporting statement for 1210-0169 changes made to questions 2(iii), 2(vi), 2(xiii), 12, 13, 14, 16

  • Also, the Department has updated the data inputs in the supporting statement

• Appendix 3: Federal Independent Dispute Resolution (IDR) Process Notice of Offer Data Elements

• Appendix 6: Certified IDR Entity’s Written Decision of Payment Determination Data Elements

HHS Documents that have been added to the ICs:

The following documents were added to the “Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities” IC:

• PPDR Payment Settlement Form

• Good Faith Estimate Template Notice

• PPDR Data Elements for Patients and Providers

• Vendor Management Data Elements

The following documents were added to the “Federal IDR Process for Air Ambulance Services” IC:

• PPDR Payment Settlement Form

• Good Faith Estimate Template Notice

• PPDR Data Elements for Patients and Providers

• Vendor Management Data Elements

The following documents were added to the “IDR Entity Certification and IDR Entity Monthly Reporting” IC:

• SDRE Selection Notice

• SDRE Entity Certification Data Elements

• SDRE Declining Eligibility or Need More Information

• SDRE Determination Notice

• SDRE Confirmation of Receipt of Settlement Information

The following document were added to the “Request of Extension of Time Periods for Extenuating Circumstances” IC:

• Request for Extension Notice