| PRA Disclosure Statement This information collection request is required by states to obtain benefits. It provides for the collection of hospital specific DSH payment information as required by section 1923(j)(1) of the Social Security Act (the Act). Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0746. The time required to complete this information collection is estimated to average 42 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. |
| Definition of Uncompensated Care: | |||||||||||||||||||
| A | B | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | |
| Hospital Name | State Estimated Hospital-Specific DSH Limit | Medicaid I/P Utilization Rate | Low-Income Utilization Rate | State-Defined Eligibility Statistic | Regular IP/OP Medicaid FFS Rate Payments | IP/OP Medicaid MCO Payments | Supplemental / Enhanced IP/OP Medicaid Payments | Total Medicaid IP/OP Medicaid Payments | Total Cost of Care - Medicaid IP/OP Services | Total Medicaid Uncompensated Care Costs | Total IP/OP Indigent Care/Self-Pay Revenues | Total Applicable Section 1011 Payments | Total IP/OP Uninsured Cost of Care | Total Uninsured Uncompensated Care Costs | Total Eligible Uncompensated Care Costs | Medicaid Provider Number | Medicare Provider Number | Total Hosptial Cost | |
| OMB Approved # 0938-0746 Expires TBD | |||||||||||||||||||
| File Type | application/vnd.ms-excel |
| Author | HCFA Software Control |
| Last Modified By | Mitch Bryman |
| File Modified | 2020-06-05 |
| File Created | 2002-04-12 |