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

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⚠️ Notice: This information collection may be referencing outdated material.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 (#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

Information Collection (IC) Details

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:

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 %

	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

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.