GenIC #32 (Extension w/o change): Provider-Preventable Conditions under 42 CFR 438.6 and 447.26 and Title 2702 Non-Payment Preprint (Attachment 4.19)

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⚠️ Notice: This information collection may be referencing outdated material.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
Form CMS-10398 #32 GenIC #32 (Extension w/o change): Provider-Preventable Conditions under 42 CFR 438.6 and 447.26 and Title 2702 Non-Payment Preprint (Attachment 4.19) Form
32 - Instructions - Provider-Preventable Conditions.docx Instruction
CMS-10398 #32 Provider-Preventable Conditions Pre Print 32 - Pre-Print - Provider-Preventable Conditions.docx Form
32 - Final Supporting Statement - Provider-Preventable Conditions.docx #32 - Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	GenIC #32 (Extension w/o change): Provider-Preventable Conditions under 42 CFR 438.6 and 447.26 and Title 2702 Non-Payment Preprint (Attachment 4.19)	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
Form	CMS-10398 #32	Provider-Preventable Conditions Pre Print	32 - Pre-Print - Provider-Preventable Conditions.docx		Yes	Yes	Fillable Fileable
Instruction			32 - Instructions - Provider-Preventable Conditions.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 55	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	2	2
Annual IC Time Burden (Hours)	78	78
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
#32 - Supporting Statement	32 - Final Supporting Statement - Provider-Preventable Conditions.docx	01/09/2018

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