Form CMS-64 SPVNarr Mockup

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1148
(CMS-10398 #73)

Medicaid Program Expenditure Report
Supplemental Payment Validation Narrative Explanations
State:
Quarter Ended: 12/31/2021
Category of Service:
Narrative Type:
Ownership Category:
Narrative

PRA Disclosure Statement The purpose of this collection of information is to collect information on all supplemental payments from Medicaid programs. This
collection is mandatory and based on statue- passage of Division CC, Title II, Section 202 of the CAA, Congress added subsection (bb) to section 1903 of the
Act, which requires the Secretary of Health and Human Services to establish a system for states to submit reports on supplemental payments as defined in
section 1903(bb)(2) of the Act, no later than October 1, 2021. 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 0938-1148 (CMS-10398 #73). The time required to complete this information
collection is estimated to average 15 hours per quarter per state (60 hours per year per state) 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.

Form CMS 64 SPVNarr