Medicaid Report on Payables and Receivables

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0697 can be found here:

Documents and Forms

Document Name Document Type
CMS-R-199.MedicaidInstructions508.pdf Instruction
R-199 Medicaid Reporting CMS-R-199 Form(2016).doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicaid Report on Payables and Receivables	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CMS-R-199.MedicaidInstructions508.pdf		Yes	Yes	Fillable Fileable
Form	R-199	Medicaid Reporting	CMS-R-199 Form(2016).doc		Yes	No	Fillable Fileable

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: 0 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	392	392
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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