Information Collection

#3: State Medicaid Recovery Audit Contractor (RAC) Program Phase II

IC 214256 under ICR 201410-0938-016 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form CMS-10398 (#3) #3: State Medicaid Recovery Audit Contractor (RAC) Program Phase II Form
CMS-10398 (#3) RACs At-A-Glance Phase II Data Collection Phase II Mockup_approved clean_12-15-14.docx State Medicaid RAC programs (“Phase II” information) Form
RAC Supporting Statement [Dec 2014].docx #3 Supporting Statement: State Medicaid Recovery Audit Contractor (RAC) Programs IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	#3: State Medicaid Recovery Audit Contractor (RAC) Program Phase II	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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 (#3)	RACs At-A-Glance Phase II Data Collection	Phase II Mockup_approved clean_12-15-14.docx	State Medicaid RAC programs (âPhase IIâ information)	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 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	1,120	1,120
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
#3 Supporting Statement: State Medicaid Recovery Audit Contractor (RAC) Programs	RAC Supporting Statement [Dec 2014].docx	12/22/2014

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