Information Collection

Bundle: #13 (UPL 1), #24 (UPL 2), and #46 (1915(i) State Plan Home and Community Based Services)

IC 224389 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⚠️ Notice: This information collection may be referencing outdated material.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
#13 - Attachment A -- NF Instructions.docx	Instruction
#13 - Attachment C -- OP Instructions.docx	Instruction
#13 - Attachment E -- IP Instructions.docx	Instruction
#24 -- I - UPL ICFID instructions final.doc	Instruction
#24 -- III - UPL Clinic Instructions Final.doc	Instruction
#24 -- V - ACR Narrative Instructions Final Draft Clean.docx	Instruction
#24 -- VII - Other facility Instructions final.docx	Instruction
#24 -- VIII - Other Facility Guidance -Final.docx	Instruction
CMS-10398 (#13) Nursing Facility UPL Guidance #13 - Attachment B -- NF Guidance.docx	Form
CMS-10398 (#13) Outpatient Hospital UPL Guidance #13 - Attachment D -- OP Guidance.docx	Form
CMS-10398 (#13) Inpatient Hospital UPL Guidance #13 - Attachment F -- IP Guidance.docx	Form
CMS-10398 (#13) Nursing Facility UPL Template #13 - Attachment G -- NF Template.xlsx	Form and Instruction
CMS-10398 (#13) Outpatient Hospital UPL Template #13 - Attachment H -- OP Template.xlsx	Form and Instruction
CMS-10398 (#13) Inpatient Hospital UPL Template #13 - Attachment I -- IP Template.xlsx	Form and Instruction
CMS-10398 (#24) Intermediate Care Facility for Individuals with Intellec #24 -- II - ICFID Guidance final.docx	Form
CMS-10398 (#24) Clinic Upper Payment Limit (UPL) Guidance #24 -- IV - UPL Clinic Guidance.docx	Form
CMS-10398 (#24) Qualified Medicaid Practitioner Enhanced Payment and Ave #24 -- VI - Phys Review Guidance.docx	Form
CMS-10398 (#24) Funding Questions #24 -- IX - Funding Questions.doc	Form
CMS-10398 (#24) Medicaid Qualified Practitioner Services (Physician) Sta #24 -- X - UPL Physician Template.xlsx	Form and Instruction
CMS-10398 (#24) Other Inpatient and Outpatient Facility (Institutes for #24 -- XI - UPL-Institute-Mental-Disease Template.xlsx	Form and Instruction
CMS-10398 (#24) Intermediate Care Facilities for Individuals with Intell #24 -- XII - UPL-Intermediate-Care-Facility Template.xlsx	Form and Instruction
CMS-10398 (#24) Other Inpatient and Outpatient Facility (Psychiatric Res #24 -- XIII - UPL-Psychiatric-Residential-Treatment-Facility Template.xlsx	Form and Instruction
CMS-10398 (#24) Clinic Standard Template #24 - XIV - UPL-Clinic Template.xlsx	Form and Instruction
CMS-10398 (#46) 1915(i) State Plan Home and Community-Based Services Adm #46 - 1915(i) Final Template.doc	Form
#13 - Supporting Statement [rev 11-04-2016 by OSORA PRA].docx #13 - Supporting Statement	IC Document
#24 - Supporting Statement [rev 11-04-2016 by OSORA PRA].docx #24 - Supporting Statement	IC Document
#46 - 1915(i) Supporting Statement [rev 11-09-2016 by OSORA PR.docx #46 - Supporting Statement	IC Document
Bundled Burden Table (11-09-2016).xlsx Bundle Burden Summary	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Bundle: #13 (UPL 1), #24 (UPL 2), and #46 (1915(i) State Plan Home and Community Based Services)

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

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			#13 - Attachment A -- NF Instructions.docx	Yes	Yes	Paper Only
Form	CMS-10398 (#13)	Nursing Facility UPL Guidance	#13 - Attachment B -- NF Guidance.docx	Yes	Yes	Fillable Fileable
Instruction			#13 - Attachment C -- OP Instructions.docx	Yes	Yes	Paper Only
Form	CMS-10398 (#13)	Outpatient Hospital UPL Guidance	#13 - Attachment D -- OP Guidance.docx	Yes	Yes	Fillable Fileable
Instruction			#13 - Attachment E -- IP Instructions.docx	Yes	Yes	Paper Only
Form	CMS-10398 (#13)	Inpatient Hospital UPL Guidance	#13 - Attachment F -- IP Guidance.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 (#13)	Nursing Facility UPL Template	#13 - Attachment G -- NF Template.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 (#13)	Outpatient Hospital UPL Template	#13 - Attachment H -- OP Template.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 (#13)	Inpatient Hospital UPL Template	#13 - Attachment I -- IP Template.xlsx	Yes	Yes	Fillable Fileable
Instruction			#24 -- I - UPL ICFID instructions final.doc	Yes	Yes	Paper Only
Form	CMS-10398 (#24)	Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/ID) UPL Guidance	#24 -- II - ICFID Guidance final.docx	Yes	Yes	Fillable Fileable
Instruction			#24 -- III - UPL Clinic Instructions Final.doc	Yes	Yes	Paper Only
Form	CMS-10398 (#24)	Clinic Upper Payment Limit (UPL) Guidance	#24 -- IV - UPL Clinic Guidance.docx	Yes	Yes	Paper Only
Instruction			#24 -- V - ACR Narrative Instructions Final Draft Clean.docx	Yes	Yes	Paper Only
Form	CMS-10398 (#24)	Qualified Medicaid Practitioner Enhanced Payment and Average Commercial Rate (ACR) Supplemental Payment Demonstration Guidance	#24 -- VI - Phys Review Guidance.docx	Yes	Yes	Paper Only
Instruction			#24 -- VII - Other facility Instructions final.docx	Yes	Yes	Paper Only
Instruction			#24 -- VIII - Other Facility Guidance -Final.docx	Yes	Yes	Paper Only
Form	CMS-10398 (#24)	Funding Questions	#24 -- IX - Funding Questions.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10398 (#24)	Medicaid Qualified Practitioner Services (Physician) Standard Template	#24 -- X - UPL Physician Template.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 (#24)	Other Inpatient and Outpatient Facility (Institutes for Mental Diseases) Standard Template	#24 -- XI - UPL-Institute-Mental-Disease Template.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 (#24)	Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) Standard Template	#24 -- XII - UPL-Intermediate-Care-Facility Template.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 (#24)	Other Inpatient and Outpatient Facility (Psychiatric Residential Treatment Facility (PRTF) Standard Template	#24 -- XIII - UPL-Psychiatric-Residential-Treatment-Facility Template.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 (#24)	Clinic Standard Template	#24 - XIV - UPL-Clinic Template.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10398 (#46)	1915(i) State Plan Home and Community-Based Services Administration and Operation	#46 - 1915(i) Final Template.doc	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 9

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
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	9	9
Annual IC Time Burden (Hours)	1,026	1,026
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
#13 - Supporting Statement	#13 - Supporting Statement [rev 11-04-2016 by OSORA PRA].docx	11/10/2016
#24 - Supporting Statement	#24 - Supporting Statement [rev 11-04-2016 by OSORA PRA].docx	11/10/2016
#46 - Supporting Statement	#46 - 1915(i) Supporting Statement [rev 11-09-2016 by OSORA PR.docx	11/10/2016
Bundle Burden Summary	Bundled Burden Table (11-09-2016).xlsx	11/10/2016

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