Information Collection

#24: Medicaid Accountability – Upper Payment Limits

IC 214329 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⚠️ Notice: This information collection may be referencing outdated material.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
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

IC Title:

#24: Medicaid Accountability â 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	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 %

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
#24 Supporting Statement: Medicaid Accountability â 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.