Information Collection

GenIC #24 (Extension w/o change): Medicaid Accountability – UPL ICF/IID, Clinic Services, Medicaid Qualified Practitioner Services and Other Inpatient & Outpatient Facility Providers

IC 229682 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⚠️ Notice: This information collection may be referencing outdated material.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
24 - I - ICFID instructions final.doc	Instruction
24 - III - Clinic Instructions Final.doc	Instruction
24 - V - ACR Narrative Instructions Final Draft Clean.docx	Instruction
24 - VII - Other facility Instructions final.docx	Instruction
#24 - Medicaid UPL Clinic Guidance.docx	Instruction
CMS-10398 #24 II - Intermediate Care Facility for Individuals with Int 24 - II - ICFID Guidance final.docx	Form and Instruction
CMS-10398 #24 IV - Clinic Upper Payment Limit (UPL) Guidance 24 - IV - Clinic UPL Guidance final.docx	Form and Instruction
CMS-10398 #24 Qualified Medicaid Practitioner Enhanced Payment and Ave 24 - VI - 4 4 Phys Review Guidance Web Version Final Draft Clean.docx	Form and Instruction
CMS-10398 #24 VIII - Other Inpatient and Outpatient Facility Provider 24 - VIII - Other Facility Guidance -Final.docx	Form and Instruction
CMS-10398 #24 UPL Physician Template 24 - X - UPL Physician Template.xlsx	Form
CMS-10398 #24 UPL Institute Mental Disease Template 1 24 - XI - UPL-Institute-Mental-Disease Template 1.xlsx	Form
CMS-10398 #24 UPL Institute Mental Disease Template 24 - XI - UPL-Institute-Mental-Disease Template.xlsx	Form
CMS-10398 #24 XII. Intermediate Care Facilitiy Template 24 - XII - UPL-Intermediate-Care-Facility Template.xlsx	Form
CMS-10398 #24 XIII - UPL Psychiatric Residential Treatment Facility (P 24 - XIII - UPL-Psychiatric-Residential-Treatment-Facility Template.xlsx	Form
CMS-10398 #24 XIV - Clinic Template #24 - Mediciad UPL-Clinic Template.xlsx	Form
CMS-10398 #24 IX - Funding Questions IX - Funding Questions.doc	Form
24 - Final Supporting Statement Medicaid Accountability.docx #24 - Supporting Statement	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

GenIC #24 (Extension w/o change): Medicaid Accountability â UPL ICF/IID, Clinic Services, Medicaid Qualified Practitioner Services and Other Inpatient & Outpatient Facility Providers

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			24 - V - ACR Narrative Instructions Final Draft Clean.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #24	Qualified Medicaid Practitioner Enhanced Payment and Average Commercial Rate (ACR) Supplemental Payment Demonstration Guidance	24 - VI - 4 4 Phys Review Guidance Web Version Final Draft Clean.docx	Yes	Yes	Fillable Fileable
Form	CMS-10398 #24	XII. Intermediate Care Facilitiy Template	24 - XII - UPL-Intermediate-Care-Facility Template.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #24	II - Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/ID) UPL Guidance	24 - II - ICFID Guidance final.docx	Yes	Yes	Fillable Fileable
Instruction			24 - III - Clinic Instructions Final.doc	Yes	Yes	Fillable Fileable
Instruction			24 - VII - Other facility Instructions final.docx	Yes	Yes	Fillable Fileable
Form	CMS-10398 #24	XIV - Clinic Template	#24 - Mediciad UPL-Clinic Template.xlsx	Yes	Yes	Fillable Printable
Form	CMS-10398 #24	XIII - UPL Psychiatric Residential Treatment Facility (PRTF) Template	24 - XIII - UPL-Psychiatric-Residential-Treatment-Facility Template.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10398 #24	IX - Funding Questions	IX - Funding Questions.doc	Yes	Yes	Fillable Fileable
Instruction			24 - I - ICFID instructions final.doc	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #24	IV - Clinic Upper Payment Limit (UPL) Guidance	24 - IV - Clinic UPL Guidance final.docx	Yes	Yes	Fillable Fileable
Form	CMS-10398 #24	UPL Institute Mental Disease Template 1	24 - XI - UPL-Institute-Mental-Disease Template 1.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10398 #24	UPL Institute Mental Disease Template	24 - XI - UPL-Institute-Mental-Disease Template.xlsx	Yes	Yes	Fillable Fileable
Instruction			#24 - Medicaid UPL Clinic Guidance.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #24	VIII - Other Inpatient and Outpatient Facility Provider Narrative Instruction	24 - VIII - Other Facility Guidance -Final.docx	Yes	Yes	Fillable Fileable
Form	CMS-10398 #24	UPL Physician Template	24 - X - UPL Physician Template.xlsx	Yes	Yes	Fillable Printable

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 %

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
#24 - Supporting Statement	24 - Final Supporting Statement Medicaid Accountability.docx	01/08/2018

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