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Federal forms, ICRs, and supporting documents

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.

Documents and Forms
Document Name
Document Type
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Form
Form
Form
Form and Instruction
Form and Instruction
Form and Instruction
Form
Form
Form
Form
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

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

Document Type Form No. Form Name Instrument File URL 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

Health Health Care Services

 

9 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 9 0 9 0 0 0
Annual IC Time Burden (Hours) 1,026 0 1,026 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.