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

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

⚠️ Notice: This information collection may be referencing outdated material.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

Information Collection (IC) Details

IC Title:	#13: Medicaid Accountability – 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:

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 %

	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

Title	Document	Date Uploaded
#13 Medicaid Accountability – 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.