Information Collection

#13: Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits

IC 214296 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10398 (#13) Inpatient Hospital UPL Guidance #13: Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form
Form CMS-10398 (#13) Nursing Facility UPL Guidance #13: Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form
Form CMS-10398 (#13) Outpatient Hospital UPL Guidance #13: Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form
IP_instructions_final_REVISED.docx	Instruction
NF instructions final.docx	Instruction
OP_instructions final.docx	Instruction
SMD_accountability_letter_CMS revised 2-1-13.docx	Instruction
CMS-10398 (#13) Inpatient Hospital UPL Guidance Inpatient Hospital UPL Guidance final.docx	Form
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
#13 Medicaid Accountability Upper Payment Limits Supporting Statement {Dec 2014].docx #13 Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	IC Document

IC Title:

#13: Medicaid Accountability â Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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			IP_instructions_final_REVISED.docx	No		Printable Only
Instruction			OP_instructions final.docx	No		Printable Only
Form	CMS-10398 (#13)	Outpatient Hospital UPL Guidance	Outpatient Hospital UPL Guidance final.docx	Yes	Yes	Fillable Printable
Instruction			SMD_accountability_letter_CMS revised 2-1-13.docx	No		Printable Only
Instruction			NF instructions final.docx	No		Printable Only
Form	CMS-10398 (#13)	Nursing Facility UPL Guidance	Nursing Facility 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

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
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	2,240	2,240
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
#13 Medicaid Accountability â Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	#13 Medicaid Accountability Upper Payment Limits 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.