Information Collection

Medicaid Report on Payables and Receivables

IC 43663 under ICR 201305-0938-003 · OMB 0938-0697.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0697 can be found here:

Documents and Forms

Document Name Document Type
CMS-R-199.MedicaidInstructions508.pdf Instruction
CMS-R-199 CMS-R-199 CMS-R-199 Revised Form(2011).doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicaid Report on Payables and Receivables	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Instruction			CMS-R-199.MedicaidInstructions508.pdf		Yes	Yes	Fillable Fileable
Form	CMS-R-199	CMS-R-199	CMS-R-199 Revised Form(2011).doc		Yes	No	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 Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	56	0	56
Annual IC Time Burden (Hours)	392	56	336
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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