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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.

Documents and Forms
Document Name
Document Type
Instruction
Instruction
Instruction
Instruction
Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form
Form
Form
Form
Form
Form
Form
IC Document
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GenIC #24 (Extension w/o change): Medicaid Accountability – UPL ICF/IID, Clinic Services, Medicaid Qualified Practitioner Services and Other Inpatient & Outpatient Facility Providers
 
New
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL 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

Health Health Care Services

 

56 0
   
State, Local, and Tribal Governments
 
   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

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.