GenIC #5 (Extension w/o change): Medicaid Payment Suspensions

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

⚠️ Notice: This information collection may be referencing outdated material.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
Form CMS-10398 #5 GenIC #5 (Extension w/o change): Medicaid Payment Suspensions Form
CMS-10398 #5 Payment Suspension Screen Shots Payment Suspension Screen Shots [rev 02-27-2012] (1).docx Form
5 Supporting Statement Medicaid Payment Suspensions rev 10-23-2017.docx GenIC #5 - Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	GenIC #5 (Extension w/o change): Medicaid Payment Suspensions	Agency IC Tracking Number:

IC Status: New

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
Form	CMS-10398 #5	Payment Suspension Screen Shots	Payment Suspension Screen Shots [rev 02-27-2012] (1).docx		Yes	Yes	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: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	1,120	1,120
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
GenIC #5 - Supporting Statement	5 Supporting Statement Medicaid Payment Suspensions rev 10-23-2017.docx	12/29/2017

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