Information Collection

GenIC #13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits

IC 245363 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⚠️ Notice: This information collection may be referencing outdated material.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
Form CMS-10398 #13 Attachment B – Nursing Facility UPL Guidance GenIC #13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form and Instruction
Form CMS-10398 #13 Attachment D – Outpatient Hospital UPL Guidance GenIC #13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form and Instruction
Form CMS-10398 #13 Attachment F – Inpatient Hospital UPL Guidance GenIC #13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form and Instruction
Form CMS-10398 #13 Attachment G – Nursing Facility Standard Template GenIC #13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form
Form CMS-10398 #13 Attachment H – Outpatient Hospital Standard Template GenIC #13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form
Form CMS-10398 #13 Attachment I – Inpatient Hospital Standard Template GenIC #13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form
13 - Attachment A - NF Instructions.docx	Instruction
13 - Attachment C - OP Instructions-NOV-2020.docx	Instruction
13 - Attachment E - IP Instructions.docx	Instruction
CMS-10398 #13 Attachment B – Nursing Facility UPL Guidance 13 - Attachment B - NF Guidance.docx	Form and Instruction
CMS-10398 #13 Attachment D – Outpatient Hospital UPL Guidance 13 - Attachment D - OP Guidance-NOV-2020.docx	Form and Instruction
CMS-10398 #13 Attachment F – Inpatient Hospital UPL Guidance 13 - Attachment F - IP Guidance.docx	Form and Instruction
CMS-10398 #13 Attachment G – Nursing Facility Standard Template 13 - Attachment-G-nursing-facility-upl-template.xlsx	Form
CMS-10398 #13 Attachment H – Outpatient Hospital Standard Template 13 - Attachment-H-outpatient-upl-template.xlsx	Form
CMS-10398 #13 Attachment I – Inpatient Hospital Standard Template 13 - Attachment-I-inpatient-hospital-upl-template.xlsx	Form
GenIC 13 -Supporting Statement 2021 version 6.docx Generic Supporting Statement	IC Document
13 - Crosswalk_Nov-2020-IP-OP-NF.xlsx Crosswalks - Attachments G (Nursing Facility), H (Outpatient Hospital), and I (Inpatient Hospital)	IC Document
Crosswalk_C.xlsx Crosswalk: Attachment C – Outpatient Hospital Narrative Instructions	IC Document
Crosswalk_D.xlsx Crosswalk: Attachment D – Outpatient Hospital UPL Guidance	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

GenIC #13 (Revision): Medicaid Accountability â Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits

Agency IC Tracking Number:

CMCS

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction		Yes	No	Printable Only
Form and Instruction	CMS-10398 #13	Yes	Yes	Fillable Fileable
Instruction		Yes	No	Printable Only
Form and Instruction	CMS-10398 #13	Yes	Yes	Fillable Printable
Instruction		Yes	No	Printable Only
Form and Instruction	CMS-10398 #13	Yes	Yes	Fillable Printable
Form	CMS-10398 #13	Yes	Yes	Fillable Printable
Form	CMS-10398 #13	Yes	Yes	Fillable Printable
Form	CMS-10398 #13	Yes	Yes	Fillable Fileable

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: 54

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
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	54	54
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Supporting Statement		01/19/2021
Crosswalks - Attachments G (Nursing Facility), H (Outpatient Hospital), and I (Inpatient Hospital)		01/19/2021
Crosswalk: Attachment C â Outpatient Hospital Narrative Instructions		01/19/2021
Crosswalk: Attachment D â Outpatient Hospital UPL Guidance		01/19/2021

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

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