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GenIC #13 (Extension w/o change): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits
Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)
OMB: 0938-1148
IC ID: 229611
OMB.report
HHS/CMS
OMB 0938-1148
ICR 201712-0938-019
IC 229611
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:
2024-09-27 - Reinstatement with change of a previously approved collection
2024-07-11 - Reinstatement without change of a previously approved collection
Documents and Forms
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
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
GenIC #13 (Extension w/o change): Medicaid Accountability – 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:
Document Type
Form No.
Form Name
Instrument File
URL
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
Federal Enterprise Architecture Business Reference Module
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 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
56
0
56
0
0
0
Annual IC Time Burden (Hours)
2,240
0
2,240
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
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.