Information Collection

Medicaid Accountability - Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits

IC 205792 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⚠️ Notice: This information collection may be referencing outdated material.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
OP_instructions final.docx	Instruction
NF instructions final.docx	Instruction
IP_instructions_final_REVISED.docx	Instruction
CMS-10398 (13) Nursing Facility UPL Guidance Nursing Facility UPL Guidance final.docx	Form
CMS-10398 (13) Outpatient Hospital UPL Guidance Outpatient Hospital UPL Guidance final.docx	Form
CMS-10398 (13) Inpatient Hospital UPL Guidance Inpatient Hospital UPL Guidance final.docx	Form
Medicaid Accountability Upper Payment Limits Supporting Statement.docx Supporting Statement part A	IC Document
SMD_accountability_letter_CMS revised 2-1-13.docx SMD - Federal and State Oversight of Medicaid Expenditures	IC Document

IC Title:

Medicaid Accountability - Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			OP_instructions final.docx	Yes	No	Fillable Printable
Instruction			NF instructions final.docx	Yes	No	Fillable Printable
Form	CMS-10398 (13)	Nursing Facility UPL Guidance	Nursing Facility UPL Guidance final.docx	Yes	Yes	Fillable Fileable
Form	CMS-10398 (13)	Outpatient Hospital UPL Guidance	Outpatient Hospital UPL Guidance final.docx	Yes	Yes	Fillable Printable
Form	CMS-10398 (13)	Inpatient Hospital UPL Guidance	Inpatient Hospital UPL Guidance final.docx	Yes	Yes	Fillable Printable
Instruction			IP_instructions_final_REVISED.docx	Yes	No	Printable Only

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	56	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
Supporting Statement part A	Medicaid Accountability Upper Payment Limits Supporting Statement.docx	02/08/2013
SMD - Federal and State Oversight of Medicaid Expenditures	SMD_accountability_letter_CMS revised 2-1-13.docx	02/08/2013

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