GenIC Inventory

NOTICE OF OFFICE OF MANAGEMENT AND BUDGET ACTION
Date

02/12/2021

Department of Health and Human Services
Centers for Medicare & Medicaid Services
FOR CERTIFYING OFFICIAL:

Perryn Ashmore

FOR CLEARANCE OFFICER:

Terry Clark

In accordance with the Paperwork Reduction Act, OMB has taken action on your request received
12/10/2020
ACTION REQUESTED: Generic IC
GenIC #59 (Revision): Medicaid Section 1115 Serious Mental Illness and Serious Emotional
IC TITLE:
Disturbance Demonstrations
ICR REFERENCE NUMBER:
201712-0938-019
AGENCY ICR TRACKING NUMBER:

CMCS

TITLE:

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS10398)
LIST OF INFORMATION COLLECTIONS: See next page
OMB ACTION: Approved without change
OMB CONTROL NUMBER:

0938-1148

The agency is required to display the OMB Control Number and inform respondents of its legal significance in
accordance with 5 CFR 1320.5(b).
EXPIRATION DATE: 03/31/2021

BURDEN:

DISCONTINUE DATE:

RESPONSES

HOURS

COSTS

Previous

6,720

154,104

0

New

6,720

154,104

0

Change due to New Statute

0

0

0

Change due to Agency Discretion

0

0

0

Change due to Agency Adjustment

0

0

0

Change due to PRA Violation

0

0

0

Difference

TERMS OF CLEARANCE:

Terms of the Generic ICR remain in effect.

OMB Authorizing Official:

Dominic J. Mancini
Deputy and Acting Administrator,
Office Of Information And Regulatory Affairs

IC Title

Form No.

GenIC #1 (Extension
CMS-10398 #1
w/o change): CHIP
Annual Report
Template System
(CARTs)
GenIC #2 (Extension
w/o change): Medicaid
Managed Care Data
Collection
GenIC #5 (Extension CMS-10398 #5
w/o change): Medicaid
Payment Suspensions
GenIC #7 (Extension CMS-10398 #7, CMSw/o change): Cycle IV 10398 #7, CMS-10398
(AI/AN Round II
#7, CMS-10398 #7
Outreach & Enrollment
Grant Final Report
Addendum) and Cycle
V (Connecting Kids to
Coverage Outreach and
Enrollment Semi-Annual
and Final

GenIc #9 (Extension
w/o change):
Application for Section
1915(b)(4) Waiver - Fee
For Service Selective
Contracting Program
GenIC #10 (Extension
w/o change): Section
1115 Demonstration
and Waiver Application

CMS-10398 #9

CMS-10398 #10, CMS10398 #10, CMS-10398
#10, CMS-10398 #10,
CMS-10398 #10, CMS10398 #10, CMS-10398
#10

GenIC #11 (Extension CMS-10398 #11
w/o change): MAGIBased Eligibility
Verification Plan
GenIC #13 (Extension CMS-10398 #13, CMSw/o change): Medicaid 10398 #13, CMS-10398
Accountability – Nursing #13, CMS-10398 #13,
Facility, Outpatient
CMS-10398 #13, CMSHospital and Inpatient 10398 #13, CMS-10398
Hospital Upper
#13, CMS-10398 #13
Payment Limits

List of ICs
Form Name
Framework for the Annual
Report of the Children’s
Health Insurance Plans
Under Title XXI of the
Social Security Act

CFR Citation

Hrs/$/Resp
2,240 / 0 / 56

2,240 / 0 / 56

Payment Suspension
Screen Shots

1,120 / 0 / 56

Cycle IV AI/AN Round II
Outreach & Enrollment
Grant Final Report
(Formerly Known as the
Semi-Annual Report),
Cycle IV AI/AN Round II
Outreach & Enrollment
Grant Final Report
Addendum, Cycle Va.
Connecting Kids to
Coverage Semi-Annual
Report Template, Cycle
Vb. Connecting Kids to
Coverage Final Report
Template
Application for Section
1915(b)(4) Waiver - Fee
For Service Selective
Contracting Program

3,388 / 0 / 202

Long Term Services
Benefit Specifications and
Provider Qualifications,
Section 1115
Demonstration Program
Application Guide, Long
Term Services and
Supports Form, Benefit
Specifications and
Provider Qualifications,
Budget Neutrality Form,
Demonstration Financing
Form, BN Table Shell
Verification Plan Template

1,600 / 0 / 5

Outpatient Hospital UPL
Guidance, Outpatient
Hospital UPL Guidance,
Inpatient Hospital UPL
Guidance, IP Template,
OP Template, NF
Template, Inpatient
Hospital UPL Guidance,
Nursing Facility UPL
Guidance

2,240 / 0 / 56

2,240 / 0 / 56

2,240 / 0 / 56

IC Title

Form No.

GenIC #15 (Extension CMS-10398 #15, CMSw/o change): Medicaid 10398 #15, CMS-10398
State Plan Eligibility
#15, CMS-10398 #15,
CMS-10398 #15, CMS10398 #15, CMS-10398
#15, CMS-10398 #15,
CMS-10398 #15, CMS10398 #15, CMS-10398
#15, CMS-10398 #15,
CMS-10398 #15, CMS10398 #15, CMS-10398
#15, CMS-10398 #15,
CMS-10398 #15, CMS10398 #15, CMS-10398
#15, CMS-10398 #15

List of ICs
Form Name
Tab S50 – Medicaid
Eligibility: Options for
Coverage Individuals
above 133% FPL, Tab
S51 – Medicaid Eligibility:
Options for Coverage
Optional Coverage of
Parents and Other
Caretaker Relatives, Tab
S94 – Medicaid Eligibility:
General Eligibility
Requirements Eligibility
Process, Tab S52 –
Medicaid Eligibility:
Options for Coverage
Reasonable Classification
of Individuals under Age
21, Tab S53 – Medicaid
Eligibility: Options for
Coverage Children with
Non IV-E Adoption
Assistance, Tab S54 –
Medicaid Eligibility:
Options for Coverage
Optional Targeted Low
Income Children, Tab A1A3 - Medicaid
Administration: State Plan
Administration/
Designation and Authority,
Tab S10 – Medicaid
Eligibility: MAGI-Based
Income Methodologies,
Tab S14 – Medicaid
Eligibility: AFDC Income
Standards, Tab S21 –
Medicaid Eligibility:
Presumptive Eligibility by
Hospitals, Tab S25 –
Medicaid Eligibility:
Mandatory Coverage
Parents and Other
Caretaker Relatives, Tab
S28 – Medicaid Eligibility:
Mandatory Coverage
Pregnant Women, Tab
S30 – Medicaid Eligibility:
Mandatory Coverage
Infants and Children under
Age 19, Tab S32 –
Medicaid Eligibility:
Mandatory Coverage
Adult Group, Tab S33 –
Medicaid Eligibility:
Mandatory Coverage
Former Foster Care
Children, Tab S55 –
Medicaid Eligibility:
Options for Coverage
Individuals with
Tuberculosis, Tab S57 –
Medicaid Eligibility:
Options for Coverage
Independent Foster Care
Adolescents, Tab S59 –

CFR Citation

Hrs/$/Resp
1,120 / 0 / 56

IC Title

GenIC #16 (Extension
w/o change): FederallyFacilitated Marketplace
(FFM) Integration Data
Collection Tool

Form No.

List of ICs
Form Name

Medicaid Eligibility:
Options for Coverage
Individuals Eligible for
Family Planning Services,
Tab S88 – Medicaid
Eligibility: Non-Financial
Eligibility State Residency,
Tab S89 – Medicaid
Eligibility: Non-Financial
Eligibility Citizenship and
Non-Citizen Eligibility
CMS-10398 #16, CMS- Federally Facilitated
10398 #16
Marketplace and State
Based Rules Integration
Charts, Federally
Facilitated Marketplace
and State Based Rules
Integration Charts

CFR Citation

Hrs/$/Resp

1,120 / 0 / 56

IC Title

Form No.

GenIC #17 (Extension CMS-10398 #17, CMSw/o change): CHIP
10398 #17, CMS-10398
State Plan Eligibility
#17, CMS-10398 #17,
CMS-10398 #17, CMS10398 #17, CMS-10398
#15, CMS-10398 #17,
CMS-10398 #17, CMS10398 #17, CMS-10398
#17, CMS-10398 #17,
CMS-10398 #17, CMS10398 #17, CMS-10398
#17, CMS-10398 #17,
CMS-10398 #17, CMS10398 #17, CMS-10398
#17, CMS-10398 #17

List of ICs
Form Name

CS9 - Eligibility Coverage From
Conception to Birth, CS10
- Eligibility - Children Who
Have Access to Public
Employee Coverage,
CS11 - Eligibility Pregnant Women Who
Have Access to Public
Employee Coverage,
CS12 - Eligibility - Dental
Only Supplemental
Coverage, CS13 Eligibility - Deemed
Newborns, CS14 Eligibility - Children
Ineligible for Medicaid as
a Result of the Elimination
of Income Disregards,
CS15 - MAGI-Based
Income Methodologies,
CS16 - Other Eligibility
Criteria - Spenddowns,
CS7 - Eligibility - Targeted
Low-Income Children,
CS28 - General Eligibility Presumptive Eligibility for
Children, CS29 - General
Eligibility - Presumptive
Eligibility for Pregnant
Women, CS19 - NonFinancial Eligibility - Social
Security Number, CS17 Non-Financial Eligibility –
Residency, CS20 - NonFinancial Eligibility Substitution of Coverage,
CS21 - Non-Financial
Eligibility - Non-Payment
of Premiums, CS23 - NonFinancial Requirements Other Eligibility Standards,
CS24 - General Eligibility Eligibility Processing,
CS27 - Non-Financial
Requirements - Other
Eligibility Standards, CS3
- Eligibility for Medicaid
Expansion Program, CS8
- Eligibility - Targeted
Low-Income Pregnant
Women
GenIC #18 (Extension CMS-10398 #18
Mock-up of Interim Form
w/o change): Alternative
for Alternative Benefit
Benefit Plans
Plans
GenIC #21 (Extension CMS-10398 #21
SPA Attachments:
w/o change): FMAP
Threshold Methodology
Claiming State Plan
for Identification of
Amendment
Applicable FMAP Rates
GenIC #22 (Extension CMS-10398 #22, CMS- Health Homes
w/o change): Health
10398 #22
Administrative
Home State Plan
Component, Health Home
Amendment (SPA)
State Plan Amendment

CFR Citation

Hrs/$/Resp
2,800 / 0 / 56

448 / 0 / 56
160 / 0 / 40

2,400 / 0 / 30

IC Title

Form No.

GenIC #24 (Extension
w/o change): Medicaid
Accountability – UPL
ICF/IID, Clinic Services,
Medicaid Qualified
Practitioner Services
and Other Inpatient &
Outpatient Facility
Providers

CMS-10398 #24, CMS10398 #24, CMS-10398
#24, CMS-10398 #24,
CMS-10398 #24, CMS10398 #24, CMS-10398
#24, CMS-10398 #24,
CMS-10398 #24, CMS10398 #24, CMS-10398
#24

GenIC #26 (Extension CMS-10398 #26
w/o change): Medicaid
Adult Core Set
Measures Reporting
Template
GenIC #27 (Extension CMS-10398 #27
w/o change): MAGI
Conversion Plan Part 2
GenIC #28 (Extension CMS-10398 #28
w/o change): MMIS
APD Template NCCI
Coding Initiative

GenIC #29 (Extension CMS-10398 #29
w/o change): Medicaid
Cost Sharing
GenIC #30 (Extension
w/o change): State
Reporting Medicaid
Payment Suspension
GenIC #31 (Extension CMS-10398 #31
w/o change): Statewide
HCBS Transition Plans
GenIC #32 (Extension CMS-10398 #32
w/o change): ProviderPreventable Conditions
under 42 CFR 438.6
and 447.26 and Title
2702 Non-Payment
Preprint (Attachment
4.19)

List of ICs
Form Name

CFR Citation

Hrs/$/Resp

XIII - UPL Psychiatric
Residential Treatment
Facility (PRTF) Template,
IX - Funding Questions, IV
- Clinic Upper Payment
Limit (UPL) Guidance,
UPL Institute Mental
Disease Template 1, UPL
Institute Mental Disease
Template, Qualified
Medicaid Practitioner
Enhanced Payment and
Average Commercial Rate
(ACR) Supplemental
Payment Demonstration
Guidance , VIII - Other
Inpatient and Outpatient
Facility Provider Narrative
Instruction, UPL Physician
Template, XII.
Intermediate
Care Facilitiy Template,
XIV - Clinic Template, II Intermediate Care Facility
for Individuals with
Intellectual Disabilities
(ICF/ID) UPL Guidance
Medicaid Adult Core Set
Measures Template

2,240 / 0 / 56

Part 2 of Modified
Adjusted Gross Income
(MAGI) Conversion Plan
Advance Planning
Document (APD)
Template for
Implementation of the
National Correct Coding
Initiative (NCCI) in a
State’s Medicaid
Management Information
System (MMIS)
Medicaid Premiums and
Cost Sharing

1,120 / 0 / 56

2,240 / 0 / 56

840 / 0 / 280

50 / 0 / 10
42 CFR 455.23

1,040 / 0 / 1,040

Sample Template For
State Settings’ Analysis

2,016 / 0 / 48

Provider-Preventable
Conditions Pre Print

78 / 0 / 2

IC Title

Form No.

GenIC #33 (Extension CMS-10398 #33
w/o change):
Opportunity for families
of Disabled Children to
Purchase Medicaid
Coverage for Such
Children (DRA 6062)
GenIC #34 (Extension CMS-10398 #34
w/o change): Model
Application Template
and Instructions for
State Child Health Plan
Under Title XXI of the
SSA, State CHIP
GenIC #35 (Extension CMS-10398 #35
w/o change): Eligibility
and Enrollment
Performance Indicators
GenIC #37 (Extension
w/o change): Managed
Care Rate Setting
Guidance
GenIC #43 (Extension
w/o change): Section
223 Demonstration
Programs to Improve
Community Mental
Health Services

List of ICs
Form Name

CFR Citation

Hrs/$/Resp

FOA Preprint

3,200 / 0 / 40

Title XXI State Plan
Template

3,200 / 0 / 40

Eligibility and Enrollment
Performance Indicators
Template

765 / 0 / 51

280 / 0 / 70

7,490 / 0 / 121

IC Title
GenIC #45 (Extension
w/o change): Maternal
and Infant Health
Quality

Form No.
CMS-10398 #45, CMS10398 #45, CMS-10398
#45, CMS-10398 #45,
CMS-10398 #45, CMS10398 #45, CMS-10398
#45, CMS-10398 #45,
CMS-10398 #45, CMS10398 #45, CMS-10398
#45, CMS-10398 #45,
CMS-10398 #45, CMS10398 #45, CMS-10398
#45, CMS-10398 #45

GenIC #46 (Extension CMS-10398 #46
w/o change): 1915(i)
State Plan Home and
Community Based
Services
GenIC #47 (Extension
w/o change): Health
Home Core Sets
GenIC #48 (Extension CMS-10398 #48
w/o change): Section
223 Demonstration
Programs to Improve
Community Mental
Health Services
GenIC #50 (Extension CMS-10398 #50
w/o change):
Community First Choice
State Plan

List of ICs
Form Name
Maternal and Infant Health
(MIH) Quality Screenshot
#2 (Postpartum Women),
Maternal and Infant Health
(MIH) Quality Screenshot
#3 (Postpartum Women),
Maternal and Infant Health
(MIH) Quality Screenshot
#4 (Postpartum Women),
Maternal and Infant Health
(MIH) Quality Screenshot
#5 (Postpartum Women),
Maternal and Infant Health
(MIH) Quality Screenshot
#7 (Postpartum Women),
Maternal and Infant Health
(MIH) Quality Screenshot
#8 (Postpartum Women),
Maternal and Infant Health
(MIH) Quality Screenshot
#9 (Postpartum Women),
Maternal and Infant Health
(MIH) Quality Screenshot
#10 (Postpartum Women),
Maternal and Infant Health
(MIH) Quality Screenshot
#2 (Women), Maternal
and Infant Health (MIH)
Quality Screenshot #4
(Women), Maternal and
Infant Health (MIH)
Quality Screenshot #5
(Women), Maternal and
Infant Health (MIH)
Quality Screenshot #6
(Women), Maternal and
Infant Health (MIH)
Quality Screenshot #1
(Postpartum Women),
Maternal and Infant Health
(MIH) Quality Screenshot
#3 (Women), Maternal
and Infant Health (MIH)
Quality Screenshot #1
(Women), Maternal and
Infant Health (MIH)
Quality Screenshot #6
(Postpartum Women)
1915(i) Template

CFR Citation

Hrs/$/Resp
112 / 0 / 112

1,026 / 0 / 9

1,200 / 0 / 30
Attachment B: Quality
Measurement Data
Reporting Templates

1,387 / 0 / 528

Community First Choice
(CFC) State Plan pre-print

560 / 0 / 56

IC Title

Form No.

GenIC #51 (Extension CMS-10398 #51, CMSw/o change): Fast Track 10398 #51, CMS-10398
Federal Review
#51, CMS-10398 #51
Process for Section
1115 Medicaid and
CHIP Demonstration
Extensions
GenIC #52 (Extension CMS-10398 #52
w/o change): Delivery
System and Provider
Payment Initiatives
Under Medicaid
Managed Care
Products
GenIC #53 (New):
CMS-10398 #53
Section 1115
Substance Use
Disorder (SUD)
Demonstration: Guide
for Developing
Implementation Plan
Protocols
GenIC #55 (New): Limit CMS-10398 #55
on Federal Financial
Participation for Durable
Medical Equipment in
Medicaid
GenIC #37 (Rev):
Managed Care Rate
Setting Guidance
GenIC #56 (New):
CMS-10398 #56
Section 1115
Demonstration: Budget
Neutrality Workbook
GenIC #34 (Revision): CMS-10398 #34
Model Application
Template and
Instructions for State
Child Health Plan Under
Title XXI of the Social
Security Act, State
Children's Health
Insurance Program
GenIC #54 - Electronic CMS-10398 #54, CMSVisit Verification (EVV) 10398 #54
Good Faith Effort
Exemption Requests
GenIC #37 (Revision)
Managed Care Rate
Setting Guidance
GenIC #57 (New):
Section 1115
Substance Use
Disorder (SUD)
Demonstration:
Monitoring Reports
Documents and
Templates

List of ICs
Form Name

CFR Citation

Hrs/$/Resp

Application Certification
Statement - Section
1115(a) Extension,
1115(e) Extension State
Certification, 1115(f)
Extension State
Certification, Extension
With Changes Template
Section 438.6(c) pre-print

450 / 0 / 3

Section 1115 Substance
Use Disorder (SUD)
Demonstration: Guide for
Developing
Implementation Plan
Protocols

784 / 0 / 49

State Fee Schedule Drop

448 / 0 / 56

264 / 0 / 264

296 / 0 / 74
PMDA Budget Neutrality
Workbook Template

1,897 / 0 / 307

Template for Child Health
Plan Under Title XXI of
The Social Security Act
Children’s Health
Insurance Program

5 / 0 / 40

EVV Good Faith Effort
Request Form (Home
Health Care Services),
EVV Good Faith Effort
Request Form (Personal
Care Services)

792 / 0 / 99

5 / 0 / 46
1, CMS-10398 #57

1115 SUD Monitoring
Report Template, 1115
SUD Metrics Template

10,080 / 0 / 455

IC Title

Form No.

GenIC #7 (Revised):
Cycle Vb (Final Report
Template for the Round
III AI/AN Cooperative
Agreements), Cycle Va
(Semi-Annual
Template), and Cycle
Vb (Monthly and Final
Report Templates)

CMS-10398 #7, CMS10398 #7, CMS-10398
#7, CMS-10398 #7,
CMS-10398 #7

List of ICs
Form Name

CFR Citation

HEALTHY KIDS Cycle Vb:
Final Report Template
(qualitative report) ,
HEALTHY KIDS Cycle Va:
Semi-Annual Report
Template (qualitative
report) , MACRA Cycle
Vb, Round III: Final
Report Template ,
HEALTHY KIDS Cycle Vb:
Monthly Report Targets vs
Other (quantitative
reporting) , HEALTHY
KIDS Cycle Vb: Monthly
Report (quantitative
reporting)
GenIC # 58 (New):
CMS-10398 #58, CMS- Monitoring Protocol Medicaid Section 1115 10398 #58, CMS-10398 Planned Metrics,
Eligibility and Coverage #58
Monitoring Report,
Demonstration
Implementation Plan
Implementation Plan
Template
and Monitoring Reports
Documents and
Templates
GenIC #34 (Revised): CMS-10398 #34, CMS- Crosswalk - Template,
Model Application
10398 #34, CMS-10398 Template for Child Health
Template and
#34
Plan Under Title XXI of
Instructions for State
the Social Security Act
Child Health Plan Under
Children’s Health
Title XXI of the Social
Insurance Program, Track
Security Act, State
Changes - Template
Children's Health
Insurance Program
GenIC # 59 (New) CMS-10398 #59, CMS- Implementation Plan
Medicaid Section 1115 10398 $59, CMS-10398 Template , Monitoring
Severe Mental Illness #59, CMS-10398 #59, Report Template ,
and Children with
CMS-10398 #59
Monitoring Workbook,
Serious Emotional
Monitoring Protocol
Disturbance
Template, Current
Demonstrations
Availability Assessment
GenIC #61 - Medicaid CMS-10398.GenIC#61 CMS-10398.GenIC#61 Disaster Relief for the
Medicaid Disaster Relief
COVID-19 National
SPA Template
Emergency State Plan
Amendment Template
and Instructions
CMS-10398.GenIC#11 CMS-10398.GenIC#11, CMS42 CFR 435.940-960 ,
(revised) - MAGI-Based CMS-10398.GenIC#11. 10398.GenIC#11.MAGI- 42 CFR 457.380(j), 42
Eligibility Verification
Based Eligibility
CFR 435.940-435.965
Plan Template and
Verification_Plan_Templat
Addendum
e Final (3-30-20), CMS10398.GenIC#11. MAGIBased Eligibility
Verification Plan
Attachment Disaster Ver
Plan Addendum FINAL (3GenIC #62 (New): Data CMS-10398 #62
Quarterly Progress Report
Collection for Section
(QPR) Template
1003 of the SUPPORT
Act

Hrs/$/Resp
5,258 / 0 / 1,634

3,080 / 0 / 140

75 / 0 / 1

3,140 / 0 / 110

168 / 0 / 56

38 / 0 / 51

840 / 0 / 60

IC Title
GenIC #60 (New):
SUPPORT Act Survey
of Housing-Related
Supports and Services
Under Medicaid to
Individuals with
Substance Use
Disorders
GenIC #52 (Revised):
Delivery System and
Provider Payment
Initiatives Under
Medicaid Managed
Care Products
GenIC #63 (Transfer) 1932(a) State Plan
Amendment Template
GenIC #64 (New):
Federal Meta-Analysis
Support: Section 1115
Substance Use
Disorder
Demonstrations
GenIC #37 (Revised):
Managed Care Rate
Setting Guidance
GenIC #1 (Revision) CHIP Annual Report
Template System
(CARTS)
GenIC #52 (Revision) Delivery System and
Provider Payment
Initiatives Under
Medicaid Managed
Care Products
GenIC #68 (New) Section 1006(b) of the
SUPPORT Act:
Medicaid Assisted
Treatment (MAT)

Form No.

List of ICs
Form Name

CFR Citation

Hrs/$/Resp

CMS-10398 #60

State Technical
Assistance Needs
Assessment Survey

26 / 0 / 51

CMS-10398 #52

Section 438.6(c) pre-print

5 / 0 / 264

CMS-10120

1932(a) State Plan
Amendment Template

70 / 0 / 12

CMS-10398 #64, CMS- Implementation Interview
10398 #64, CMS-10398 Protocol with Instructions
#64
for Interviewer,
Demonstration
Characteristics Interview
Questions, Demonstration
Characteristics Interview
Email Invitation and Grid

162 / 0 / 54

307 / 0 / 61
CMS-10398 #1

CHIP Annual Report
Template System
(CARTS)

5 / 0 / 56

CMS-10398 #52

Section 438.6(c) Preprint

5 / 0 / 132

CMS-10398 #68, CMS- SPA Coverage Template
10398 #68
for Limitations
(Supplement to
Attachment 3.1-B), SPA
Coverage Template for
Limitations (Supplement
to Attachment 3.1-A)
GenIC #59 (Revision): CMS-10398 #59, CMS- Initial Availability
Medicaid Section 1115 10398 #59, CMS-10398 Assessment,
Serious Mental Illness #59, CMS-10398 #59, Implementation Plan
and Serious Emotional CMS-10398 #59, CMS- Template, Monitoring
Disturbance
10398 #59
Report Template,
Demonstrations
Monitoring Report
Workbook, Monitoring
Protocol Template,
Monitoring Protocol
Workbook
GenIC #1 (Revised):
#1
CARTS
CHIP Annual Report
Template System
(CARTS)

4,485 / 0 / 66

160 / 0 / 80

5 / 0 / 51

IC Title

Form No.

GenIC #13 (Revision): CMS-10398 #13, CMSMedicaid Accountability 10398 #13, CMS-10398
– Nursing Facility,
#13, CMS-10398 #13,
Outpatient Hospital and CMS-10398 #13, CMSInpatient Hospital Upper 10398 #13
Payment Limits

List of ICs
Form Name

CFR Citation

Attachment D – Outpatient
Hospital UPL Guidance,
Attachment H – Outpatient
Hospital Standard
Template, Attachment G –
Nursing Facility Standard
Template, Attachment F –
Inpatient Hospital UPL
Guidance, Attachment B –
Nursing Facility UPL
Guidance, Attachment I –
Inpatient Hospital
Standard Template
GenIC # 24 (Revision): CMS-10398 #24, CMS- XII.
Institutes for
Medicaid Accountability 10398 #24, CMS-10398 Mental Diseases (IMD)
– Upper Payment Limits #24, CMS-10398 #24, Standard Template, XIV.
for Clinics, Physician
CMS-10398 #24, CMSPsychiatric
ServicesICF/DD),
10398 #24, CMS-10398 Residential Treatment
PRTFs, and IMDs
#24, CMS-10398 #24, Facility (PRTF) Standard
CMS-10398 #24, CMS- Template, XV.
Clinic
10398 #24
Standard Template, XIII.
Intermediate
Care Facilities for
Individuals with
Intellectual Disabilities
(ICF/IID) Standard
Template, XI.
Medicaid
Qualified Practitioner
Services (Physician)
Standard Template, IX.
Other Inpatient and
Outpatient Facility
Provider Narrative
Instruction, VII. Medicaid
Qualified Practitioner
Services (Physician) UPL
Guidance, IV. Guidance Medicare Payment-Based
Clinic UPL Demonstration,
II. Intermediate Care
Facility for Individuals with
Intellectual Disabilities
(ICF/ID) UPL Guidance,
V. Clinic Upper Payment
Limit (UPL) Guidance
Total Hours Actually Used for Information Collections Under Currently Approved ICR:

Hrs/$/Resp
5 / 0 / 54

5 / 0 / 54

87,060