Requirements Related to Surprise Billing; Part II; Patient-Provider Dispute Resolution Process

Patient Provider Dispute Resolution Requirements Related to Surprise Billing: Part II (CMS-10853)

OMB: 0938-1470

IC ID: 262051

Documents and Forms

Document Name Document Type
Form CMS-10853 Requirements Related to Surprise Billing; Part II; Patient-Provider Dispute Resolution Process Form and Instruction
CMS-10853 Ineligible for Patient-Provider Dispute Resolution or Ad Appendix 1 SDRE Declining Eligibility or Need More Information Notice.pdf Form and Instruction
CMS-10853 Ineligible for Patient-Provider Dispute Resolution or Ad Appendix 1 SDRE Declining Eligibility or Need More Information Notice.pdf Form and Instruction
CMS-10853 Patient-Provider Dispute Resolution Form Appendix 2 PPDR Dispute Initiation Form Notice.pdf Form and Instruction
CMS-10853 Patient-Provider Dispute Resolution Form (English) Appendix 2 PPDR Dispute Initiation Form Notice.pdf Form and Instruction
cms-10853 SDR Entity Certification Application Data Elements Appendix 3 SDR Entity Certification Data Elements.pdf Form and Instruction
cms-10853 SDR Entity Certification Application Data Elements (Engl Appendix 3 SDR Entity Certification Data Elements.pdf Form and Instruction
CMS-10853 Vendor Management Data Elements Appendix 4 HHS Vendor Management (VM) Data Elements.pdf Form and Instruction
CMS-10853 Vendor Management Data Elements (English) Appendix 4 HHS Vendor Management (VM) Data Elements.pdf Form and Instruction
CMS-10853 Patient-Provider Dispute Resolution Process Data Element Appendix 5 HHS PPDR Data Elements for Patients and Providers.pdf Form and Instruction
CMS-10853 Patient-Provider Dispute Resolution Process Data Element Appendix 5 HHS PPDR Data Elements for Patients and Providers.pdf Form and Instruction
CMS-10853 Selected Dispute Resolution (SDR) Determination Notice Appendix 6 PPDR-SDRE Determination Notice.pdf Form and Instruction
CMS-10853 Selected Dispute Resolution (SDR) Determination Notice ( Appendix 6 PPDR-SDRE Determination Notice.pdf Form and Instruction
CMS-10853 SDRE Selection Notice Appendix 7 PPDR-SDRE Selection Notice.pdf Form and Instruction
CMS-10853 SDRE Selection Notice (English) Appendix 7 PPDR-SDRE Selection Notice.pdf Form and Instruction
CMS-10853 Payment Settlement Form (PPDR) Appendix 8 PPDR-Payment Settlement Form Notice.pdf Form and Instruction
CMS-10853 Payment Settlement Form (PPDR) - English Appendix 8 PPDR-Payment Settlement Form Notice.pdf Form and Instruction
CMS-10853 SDRE Confirmation of Receipt of Settlement Notice Appendix 9 SDRE Confirmation of Receipt of Settlement Notice.pdf Form and Instruction
CMS-10853 SDRE Confirmation of Receipt of Settlement Notice (Engli Appendix 9 SDRE Confirmation of Receipt of Settlement Notice.pdf Form and Instruction
CMS-10853 Request for Extension Notice Appendix 10 Request for Extension Notice.pdf Form and Instruction
CMS-10853 Request for Extension Notice (English) Appendix 10 Request for Extension Notice.pdf Form and Instruction
CMS-10853 Request for Extension (Spanish) Appendix 10 Request for Extension Notice-508_Spanish_Final.pdf Form and Instruction
CMS-10853 SDRE Confirmation of Receipt of Settlement (Spanish) Appendix 9 SDRE Confirmation of Receipt of Settlement Notice-508_Spanish_Final.pdf Form and Instruction
CMS-10853 PPDR Payment Settlement Form Notice (Spanish) Appendix 8 PPDR-Payment Settlement Form Notice-Clean_Spanish_Final.pdf Form and Instruction
CMS-10853 PPDR-SDRE Selective Notice (Spanish) Appendix 7 PPDR-SDRE Selection Notice-Clean_Spanish_Final.pdf Form and Instruction
cms-10853 PPDR-SDRE Determination Notice (Spanish) Appendix 6 PPDR-SDRE Determination Notice-508_Spanish_Final.pdf Form and Instruction
CMS-10853 PPDR Dispute Initiation Form Notice (Spanish) Appendix 2 PPDR Dispute Initiation Form Notice-Clean_Spanish_Final.pdf Form and Instruction
CMS-10853 SDRE Declining Eligibility and Need More Information Not Appendix 1 SDRE Declining Eligibility or Need More Information Notice-Clean_Spanish_Final.pdf Form and Instruction
CMS-10853 SDRE Declining Eligibility or Need More Information Noti (Arabic) Appendix 1 SDRE Declining Eligibility or Need More Information Notice_508.pdf Form and Instruction
CMS-10853 PPDR Dispute Initiation Form (Arabic) Appendix 2 PPDR Dispute Initiation Form Notice_508.pdf Form and Instruction
CMS-10853 PPDR-SDRE Determination Notice (Arabic) Appendix 6 PPDR-SDRE Determination Notice_508.pdf Form and Instruction
CMS-10853 PPDR-SDRE Selection Notice (Arabic) (Arabic) Appendix 7 PPDR-SDRE Selection Notice_508.pdf Form and Instruction
CMS-10853 PPDR Payment Settlement Form (Arabic) (Arabic) Appendix 8 PPDR-Payment Settlement Form Notice_508.pdf Form and Instruction
CMS-10853 SDRE Confirmation of Receipt of Settlement Notice (Arabi (Arabic) Appendix 9 SDRE Confirmation of Receipt of Settlement Notice_508.pdf Form and Instruction
CMS-10853 Request for Extension Notice (Arabic) (Arabic) Appendix 10 Request for Extension Notice_508.pdf Form and Instruction
CMS-10853 Request for Extension Notice (Chinese) (Chiense) Appendix 10 Request for Extension Notice_508.pdf Form and Instruction
CMS-10853 SDRE Confirmation of Receipt of Settlement Notice (Chine (Chinese) Appendix 9 SDRE Confirmation of Receipt of Settlement Notice_508.pdf Form and Instruction
CMS-10853 PPDR Payment Settlement Form Notice (Chinese) (Chinese) Appendix 8 PPDR-Payment Settlement Form Notice_508.pdf Form and Instruction
CMS-10853 PPDR-SDRE Selection Notice (Chinese) (Chinese) Appendix 7 PPDR-SDRE Selection Notice_508.pdf Form and Instruction
CMS-10853 PPDR-SDRE Determination Notice (Chinese) (Chinese) Appendix 6 PPDR-SDRE Determination Notice_508.pdf Form and Instruction
CMS-10853 PPDR Dispute Initiation Form Notice (Chinese) (Chinese) Appendix 2 PPDR Dispute Initiation Form Notice_508.pdf Form and Instruction
CMS-10853 SDRE Declining Eligibility or Need More Information Noti (Chinese) Appendix 1 SDRE Declining Eligibility or Need More Information Notice_508.pdf Form and Instruction
CMS-10853 SDRE Declining Eligibility or Need More Information Noti (French) Appendix 1 SDRE Declining Eligibility or Need More Information Notice_508.pdf Form and Instruction
CMS-10853 PPDR Dispute Initiation Form Notice (French) (French) Appendix 2 PPDR Dispute Initiation Form Notice_508.pdf Form and Instruction
CMS-10853 PPDR-SDRE Determination Notice (French) (French) Appendix 6 PPDR-SDRE Determination Notice_508.pdf Form and Instruction
CMS-10853 PPDR-SDRE Selection Notice (French) (French) Appendix 7 PPDR-SDRE Selection Notice_508.pdf Form and Instruction
CMS-10853 PPDR Payment Settlement Form Notice (French) (French) Appendix 8 PPDR-Payment Settlement Form Notice_508.pdf Form and Instruction
CMS-10853 SDRE Confirmation of Receipt of Settlement Notice (Frenc (French) Appendix 9 SDRE Confirmation of Receipt of Settlement Notice_508.pdf Form and Instruction
CMS-10853 Request for Extension Notice (French) (French) Appendix 10 Request for Extension Notice_508.pdf Form and Instruction
CMS-10853 SDRE Declining Eligibility or Need More Information Noti (Korean) Appendix 1 SDRE Declining Eligibility or Need More Information Notice_508.pdf Form and Instruction
CMS-10853 PPDR Dispute Initiation Form Notice (Korean) (Korean) Appendix 2 PPDR Dispute Initiation Form Notice-508.pdf Form and Instruction
CMS-10853 PPDR Dispute Initiation Form Notice (Korean) (Korean) Appendix 7 PPDR-SDRE Selection Notice_508.pdf Form and Instruction
CMS-10853 SDRE Declining Eligibility or Need More Information Noti (Tagalog) Appendix 1 SDRE Declining Eligibility or Need More Information Notice_508.pdf Form and Instruction
cms-10853 PPDR Dispute Initiation Form Notice (Tagalog) (Tagalog) Appendix 2 PPDR Dispute Initiation Form Notice_508.pdf Form and Instruction
CMS-10853 PPDR-SDRE Determination Notice (Tagalog) (Tagalog) Appendix 6 PPDR-SDRE Determination Notice_508.pdf Form and Instruction
cms-10853 PPDR-SDRE Selection Notice (Tagalog) (Tagalog) Appendix 7 PPDR-SDRE Selection Notice_508.pdf Form and Instruction
CMS-10853 PPDR-Payment Settlement Form Notice (Tagalog) (Tagalog) Appendix 8 PPDR-Payment Settlement Form Notice_508.pdf Form and Instruction
CMS-10853 SDRE Confirmation of Receipt of Settlement Notice (Tagal (Tagalog) Appendix 9 SDRE Confirmation of Receipt of Settlement Notice_508.pdf Form and Instruction
CMS-10853 Request for Extension Notice (Tagalog) (Tagalog) Appendix 10 Request for Extension Notice_508.pdf Form and Instruction
CMS-10853 SDRE Declining Eligibility or Need More Information Noti (Vietnamese) Appendix 1 SDRE Declining Eligibility or Need More Information Notice_508.pdf Form and Instruction
CMS-10853 PPDR Dispute Initiation Form Notice (Vietnamese) (Vietnamese) Appendix 2 PPDR Dispute Initiation Form Notice_508.pdf Form and Instruction
CMS-10853 PPDR-SDRE Determination Notice (Vietnamese) (Vietnamese) Appendix 6 PPDR-SDRE Determination Notice_508.pdf Form and Instruction
CMS-10853 PPDR-SDRE Selection Notice (Vietnamese) (Vietnamese) Appendix 7 PPDR-SDRE Selection Notice_508.pdf Form and Instruction
CMS-10853 PPDR Payment Settlement Form Notice (Vietnamese) (Vietnamese) Appendix 8 PPDR-Payment Settlement Form Notice_508.pdf Form and Instruction
CMS-10853 SDRE Confirmation of Receipt of Settlement Notice (Vietn (Vietnamese) Appendix 9 SDRE Confirmation of Receipt of Settlement Notice_508.pdf Form and Instruction
CMS-108i53 Request for Extension Notice (Vietnamese) (Vietnamese) Appendix 10 Request for Extension Notice_508.pdf Form and Instruction