Information Collection

#30: State Reporting Medicaid Payment Suspension

IC 214360 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⚠️ Notice: This information collection may be referencing outdated material.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
#30 Supporting Statement - State Reporting Medicaid Payment Suspension [Dec 2014].docx #30 Supporting Statement: State Reporting Medicaid Payment Suspension IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	#30: State Reporting Medicaid Payment Suspension	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 455.23

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 35	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	1,040	1,040
Annual IC Time Burden (Hours)	1,040	1,040
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
#30 Supporting Statement: State Reporting Medicaid Payment Suspension	#30 Supporting Statement - State Reporting Medicaid Payment Suspension [Dec 2014].docx	12/23/2014

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