Information Collection

State Plan Requirements - Amending FFS Rate

IC 202302 under ICR 201411-0938-009 · OMB 0938-1170.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10422 State Plan Requirements - Amending FFS Rate	Form
CMS-10422 Reimbursement Template - Physician Services (Increased P SPA Template-7-30-14_508_comp.pdf	Form
Crosswalk for Changes to Payments for Services Furnished by Certain Primary Care Providers- 508comp.pdf Crosswalk	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 447.410(a) and (b)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10422	Reimbursement Template - Physician Services (Increased Primary Care Service Payment 42 CFR 447.405, 447.210, 447.415)	SPA Template-7-30-14_508_comp.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 51

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	51	0	51
Annual IC Time Burden (Hours)	255	-765	1,020
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	Crosswalk for Changes to Payments for Services Furnished by Certain Primary Care Providers- 508comp.pdf	11/18/2014

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