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No Surprises Act: IDR Process
ICR 202302-1210-003
OMB: 1210-0169
Federal Form Document
OMB.report
DOL/EBSA
OMB 1210-0169
ICR 202302-1210-003
( )
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 1210-0169 can be found here:
2023-11-03 - Revision of a currently approved collection
2023-02-24 - RCF Recertification
Forms and Documents
Document
Name
Status
IDR- No Material Justification 02-24-2023.docx
Justification for No Material/Nonsubstantive Change
2023-02-24
Consolidated 1210-0169 Tri-dept PRA supporting statement 11.9.2022 (clean).docx
Supporting Statement A
2022-11-09
IC Document Collections
IC ID
Document
Title
Status
254938
Additional Information to Be Shared with the Initial Payment or Notice of Denial of Payment
Other-Disclosure Requirement
Unchanged
249371
Request of Extension of Time Periods for Extenuating Circumstances
Other-Request of Extension of Time Periods for Extenuating Circu
Unchanged
248857
IDR Entity Certification and IDR Entity Monthly Reporting
Other-IDR Certification Application
Modified
248850
Federal IDR Process for Air Ambulance Services
Other-Notice of Open Negotiation
Modified
248846
Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities
Other-Notice of Open Negotiation
Modified
ICR Details
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