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)

⚠️ Notice: This information collection may be referencing outdated material.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
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

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	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 %

	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

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.