Information Collection

Medicaid - Title Xix Superior Utilization Review (ur) System Waiver Request Information Collection Requirement Sections 9320-9330 Of The State Medicaid Manual

IC 113828 under ICR 198605-0938-007 · OMB 0938-0479.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0479 can be found here:

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Information Collection (IC) Details

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IC Title:	MEDICAID - TITLE XIX SUPERIOR UTILIZATION REVIEW (UR) SYSTEM WAIVER REQUEST INFORMATION COLLECTION REQUIREMENT SECTIONS 9320-9330 OF THE STATE MEDICAID MANUAL	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-R-95				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 25	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	25	25
Annual IC Time Burden (Hours)	300	300
Annual IC Cost Burden (Dollars)	0	0

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.