Information Collection

GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs

IC 245368 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⚠️ Notice: This information collection may be referencing outdated material.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 #24 II. Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/ID) UPL Guidance GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs	Form and Instruction
Form CMS-10398 #24 V. Clinic Upper Payment Limit (UPL) Guidance GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs	Form and Instruction
Form CMS-10398 #24 VII. Medicaid Qualified Practitioner Services (Physician) UPL Guidance GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs	Form and Instruction
Form CMS-10398 #24 IX. Other Inpatient and Outpatient Facility Provider Narrative Instruction GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs	Form and Instruction
Form CMS-10398 #24 XI. Medicaid Qualified Practitioner Services (Physician) Standard Template GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs	Form
Form CMS-10398 #24 XII. Institutes for Mental Diseases (IMD) Standard Template GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs	Form
Form CMS-10398 #24 XIII. Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) Standard Template GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs	Form
Form CMS-10398 #24 XIV. Psychiatric Residential Treatment Facility (PRTF) Standard Template GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs	Form
Form CMS-10398 #24 XV. Clinic Standard Template GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs	Form
Form CMS-10398 #24 IV. Guidance - Medicare Payment-Based Clinic UPL Demonstration GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs	Form and Instruction

Information Collection (IC) Details

Record metadata
IC Title	GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs