Information Collection

MMIS APD Template NCCI Coding Initiative (Information Collection #28)

IC 210243 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⚠️ Notice: This information collection may be referencing outdated material.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 (#28) MMIS APD Template NCCI Coding Initiative (Information Collection #28)	Form
CMS-10398 (#28) Advance Planning Document (APD) Template for Implementat MedicaidNCCIAPDFinal 508 version [rev 1-30-2014 by OSORA PRA].pdf	Form
CrosswalkMedicaidNCCIAPDTemplate.pdf Crosswalk	IC Document
MMISAPDTemplateNCCICodingSupportingStatement [rev 01-30-2014 by OSORA PRA].docx Supporting Statement	IC Document

IC Title:

MMIS APD Template NCCI Coding Initiative (Information Collection #28)

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10398 (#28)	Advance Planning Document (APD) Template for Implementation of the National Correct Coding Initiative (NCCI) in a State's Medicaid Management Information System (MMIS)	MedicaidNCCIAPDFinal 508 version [rev 1-30-2014 by OSORA PRA].pdf		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: 0 %

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	280	0	0	0	0	0
Annual IC Time Burden (Hours)	840	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
Crosswalk	CrosswalkMedicaidNCCIAPDTemplate.pdf	01/30/2014
Supporting Statement	MMISAPDTemplateNCCICodingSupportingStatement [rev 01-30-2014 by OSORA PRA].docx	01/30/2014

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