CHIP Annual Report Template System (CARTs)

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10398-001 CHIP Annual Report Template System (CARTs) Form
CMS-10398-001 CHIP Annual Report Template System (CARTs) CARTS Template [rev 12-19-11].doc Form
CMS-10398-002 2011 National Summary Data Dictionary Att 1-NSDD2011f.docx Form and Instruction
CMS-10398-002 2011 Medicaid Managed Care Enrollment Data Dictionary Att 2-2011ERDDf.docx Form and Instruction
CMS-10398-003 Medicaid Recovery Audit Contractor (RAC) Program Phase II Mockup_approved clean_11-15-11.docx Form
MMC Supporting Statement.docx CMS-10398-002 - MMC Supporting Statement part A IC Document
CARTS Supporting Statement.docx CMS-10398-001 - CARTS Supporting Statement part A IC Document
RAC Supporting Statement.docx CMS-10398-003 RAC Supporting Statement part A IC Document

Information Collection (IC) Details

IC Title:	CHIP Annual Report Template System (CARTs)	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10398-001	CHIP Annual Report Template System (CARTs)	CARTS Template [rev 12-19-11].doc	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10398-002	2011 National Summary Data Dictionary	Att 1-NSDD2011f.docx	Yes	Yes	Printable Only
Form and Instruction	CMS-10398-002	2011 Medicaid Managed Care Enrollment Data Dictionary	Att 2-2011ERDDf.docx	Yes	Yes	Printable Only
Form	CMS-10398-003	Medicaid Recovery Audit Contractor (RAC) Program	Phase II Mockup_approved clean_11-15-11.docx	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 56	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	168	0	0	0	0	0
Annual IC Time Burden (Hours)	5,600	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-10398-002 - MMC Supporting Statement part A	MMC Supporting Statement.docx	12/19/2011
CMS-10398-001 - CARTS Supporting Statement part A	CARTS Supporting Statement.docx	12/19/2011
CMS-10398-003 RAC Supporting Statement part A	RAC Supporting Statement.docx	12/19/2011

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