Information Collection

Medicaid Report on Payables and Receivables (R-199)

IC 43663 under ICR 202002-0938-009 · OMB 0938-0697.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-R-199 Medicaid Report on Payables and Receivables (R-199)	Form
CMS-R-199Validation Letter_2020_508.pdf	Instruction
CMS-R-199 MEDICAID INCURRED BUT NOT REPORTED (IBNR) SURVEY CMS-R-199Form(2019)_508_10-22-19.pdf	Form
CMS-R-199 System Crosswalk_508_10-11-19.pdf Crosswalk	IC Document

IC Title:

Agency IC Tracking Number:

OFM

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-R-199	MEDICAID INCURRED BUT NOT REPORTED (IBNR) SURVEY	CMS-R-199Form(2019)_508_10-22-19.pdf		Yes	No	Fillable Fileable
Instruction			CMS-R-199Validation Letter_2020_508.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	56	0	56
Annual IC Time Burden (Hours)	1,792	1,400	392
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	CMS-R-199 System Crosswalk_508_10-11-19.pdf	02/14/2020

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