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GenIC #57 (New): Section 1115 Substance Use Disorder (SUD) Demonstration: Monitoring Reports Documents and Templates

IC 236005 under ICR 201712-0938-019 · OMB 0938-1148.

Documents and Forms
Document Name
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Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Form
Form
IC Document
IC Document
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GenIC #57 (New): Section 1115 Substance Use Disorder (SUD) Demonstration: Monitoring Reports Documents and Templates CMCS
 
New
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction SUD Monitoring Protocol Template Instructions (version 4).docx Yes No Printable Only
Instruction Populating and Submitting Monitoring Templates.docx https://cvpcorp-1115pmda.adobeconnect.com/pklt7cdlhgjl/ Yes No Printable Only
Instruction Overview of the Standardized Monitoring Report Process.docx https://cvpcorp-1115pmda.adobeconnect.com/pqopfoy48idv/ Yes No Printable Only
Instruction Downloading 1115 Monitoring Report Templates.docx https://cvpcorp-1115pmda.adobeconnect.com/p4l83cvhhqda/ Yes Yes Printable Only
Form 1 1115 SUD Monitoring Report Template 1115 SUD Monitoring Report Template (version 4).docx Yes Yes Fillable Fileable
Form CMS-10398 #57 1115 SUD Metrics Template Copy of Copy of 1115 SUD Metrics Workbook 3_1 (version 4).xlsx Yes Yes Fillable Fileable
Instruction 1115 SUD Monitoring Protocol Template (version 4).docx Yes No Printable Only
Instruction SUD Monitoring Report Template Instructions (version 4).docx Yes No Printable Only

Health Health Care Services

 

35 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved 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 455 0 455 0 0 0
Annual IC Time Burden (Hours) 10,080 0 10,080 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
State Medicaid Directors letter #17-003 smd #17-003.pdf 05/07/2019
Supporting Statement A Supporting Statement A Health Policy Booklets Local Gov 031119.docx 05/20/2019
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.