Information Collection

(GenIC 1) At a Glance Phase III & (GenIC 2) Medicaid Payment Suspensions

IC 201365 under ICR 201111-0938-009 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10398-004 (GenIC 1) At a Glance Phase III & (GenIC 2) Medicaid Payment Suspensions	Form
CMS-10398-004 Recovery Audit Contractor (RAC) Programs at a Glance (Ph RAC Phase III Mock Ups [rev 02-27-2012].doc	Form
CMS-10398-005 State Medicaid Payment Suspensions Payment Suspension Screen Shots [rev 02-27-2012].docx	Form
RAC At A Glance Supporting Statement.docx CMS-10398-004 - Supporting Statement for RAC Programs at a Glance (Phase III)	IC Document
Medicaid Payment Suspensions Supporting Statement.docx CMS-10398-005 - Supporting Statement for State Medicaid Payment Suspensions	IC Document

IC Title:

(GenIC 1) At a Glance Phase III & (GenIC 2) Medicaid Payment Suspensions

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10398-004	Recovery Audit Contractor (RAC) Programs at a Glance (Phase III)	RAC Phase III Mock Ups [rev 02-27-2012].doc		Yes	Yes	Fillable Printable
Form	CMS-10398-005	State Medicaid Payment Suspensions	Payment Suspension Screen Shots [rev 02-27-2012].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 %

table that charts list of burden
	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	112	0	0	0	0	0
Annual IC Time Burden (Hours)	2,240	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10398-004 - Supporting Statement for RAC Programs at a Glance (Phase III)	RAC At A Glance Supporting Statement.docx	02/27/2012
CMS-10398-005 - Supporting Statement for State Medicaid Payment Suspensions	Medicaid Payment Suspensions Supporting Statement.docx	02/27/2012

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