Information Collection

GenIC #13 (Extension w/o change): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits

IC 229611 under ICR 201712-0938-019 · 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⚠️ Notice: This information collection may be referencing outdated material.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
CMS-10398 #13 Nursing Facility UPL Guidance 13 - Attachment B -- NF Guidance.docx	Form and Instruction
CMS-10398 #13 Outpatient Hospital UPL Guidance 13 - Attachment D -- OP Guidance.docx	Form and Instruction
CMS-10398 #13 Inpatient Hospital UPL Guidance 13 - Attachment F -- IP Guidance.docx	Form and Instruction
CMS-10398 #13 NF Template 13 - Attachment G -- NF Template.xlsx	Form
CMS-10398 #13 OP Template 13 - Attachment H -- OP Template.xlsx	Form
CMS-10398 #13 IP Template 13 - Attachment I -- IP Template.xlsx	Form
CMS-10398 #13 Inpatient Hospital UPL Guidance 13 - Inpatient Hospital UPL Guidance final.docx	Form
CMS-10398 #13 Outpatient Hospital UPL Guidance 13 - Outpatient Hospital UPL Guidance final.docx	Form
13 - Supporting Statement Medicaid Accountability Nursing Outpatient Hospital and Inpatient Hospital Upper Payment Limits.docx #13 - Supporting Statement	IC Document

IC Title:

GenIC #13 (Extension w/o change): Medicaid Accountability â Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits

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 C -- OP Instructions.docx	No		Printable Only
Form and Instruction	CMS-10398 #13	Outpatient Hospital UPL Guidance	13 - Attachment D -- OP Guidance.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #13	Inpatient Hospital UPL Guidance	13 - Attachment F -- IP Guidance.docx	Yes	Yes	Fillable Fileable
Form	CMS-10398 #13	NF Template	13 - Attachment G -- NF Template.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10398 #13	OP Template	13 - Attachment H -- OP Template.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10398 #13	IP Template	13 - Attachment I -- IP Template.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10398 #13	Inpatient Hospital UPL Guidance	13 - Inpatient Hospital UPL Guidance final.docx	Yes	Yes	Fillable Fileable
Form	CMS-10398 #13	Outpatient Hospital UPL Guidance	13 - Outpatient Hospital UPL Guidance final.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #13	Nursing Facility UPL Guidance	13 - Attachment B -- NF Guidance.docx	Yes	Yes	Fillable Fileable
Instruction			13 - Attachment A -- NF Instructions.docx	No		Printable Only

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 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	2,240	2,240
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 Medicaid Accountability Nursing Outpatient Hospital and Inpatient Hospital Upper Payment Limits.docx	12/29/2017

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