#24: Medicaid Accountability – 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⚠️ Notice: This information collection may be referencing outdated material.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
I - ICFID instructions final.doc Instruction
II - ICFID Guidance final.docx Instruction
III - Clinic Instructions Final.doc Instruction
IV - Clinic UPL Guidance final.docx Instruction
V - ACR Narrative Instructions Final Draft Clean.docx Instruction
VI - 4 4 Phys Review Guidance Web Version Final Draft Clean.docx Instruction
VII - Other facility Instructions final.docx Instruction
VIII - Other Facility Guidance -Final.docx Instruction
IX - Funding Questions.doc Instruction
#24 Medicaid Accountability UPL Part 2 Supporting Statement [Dec 2014].docx #24 Supporting Statement: Medicaid Accountability – Upper Payment Limits IC Document

Information Collection (IC) Details

IC Title:	#24: Medicaid Accountability – 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	Instrument File	Available Electronically?	Electronic Capability
Instruction	I - ICFID instructions final.doc	No	Printable Only
Instruction	III - Clinic Instructions Final.doc	No	Printable Only
Instruction	VII - Other facility Instructions final.docx	No	Printable Only
Instruction	VIII - Other Facility Guidance -Final.docx	No	Fillable Printable
Instruction	II - ICFID Guidance final.docx	No	Printable Only
Instruction	IV - Clinic UPL Guidance final.docx	No	Printable Only
Instruction	V - ACR Narrative Instructions Final Draft Clean.docx	No	Printable Only
Instruction	VI - 4 4 Phys Review Guidance Web Version Final Draft Clean.docx	No	Fillable Printable
Instruction	IX - Funding Questions.doc	No	Printable Only

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
#24 Supporting Statement: Medicaid Accountability – Upper Payment Limits	#24 Medicaid Accountability UPL Part 2 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.