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#13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits

IC 251147 under ICR 202401-0938-016 · OMB 0938-1148.

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Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form
Form
Form
Form
Form
Form
IC Document
IC Document
IC Document
IC Document
IC Document
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Information Collection (IC) Details

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#13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits CMCS
 
Unchanged
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10398 #13 MACFIN_inpatient-upl-template V MACFIN_inpatient-upl-template.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10398 #13 MACFIN_outpatient-upl-template VI MACFIN_outpatient-upl-template.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10398 #13 MACFIN_nursing-facility-upl-template VII MACFIN_nursing-facility-upl-template.xlsx Yes Yes Fillable Fileable
Form CMS-10398 #13 Guidance Questions: Inpatient VIII UPL Guidance Questions_Master File_Inpatient.pdf Yes Yes Fillable Fileable
Form CMS-10398 #13 Guidance Questions: Nursing IX UPL Guidance Questions_Master File_Nursing Facility.pdf Yes Yes Fillable Fileable
Form CMS-10398 #13 Guidance Questions: Outpatient X UPL Guidance Questions_Master File_Outpatient.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

54 0
   
State, Local, and Tribal Governments
 
   100 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 54 0 0 0 0 54
Annual IC Time Burden (Hours) 5 0 0 0 0 5
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Crosswalk-Guidance-Instructions (inpatient hospital, outpatient hospital, and nursing facility) I Crosswalk-Guidance-Instructions_PRA-13.xlsx 01/14/2022
Template Crosswalk: (Templates: inpatient hospital, outpatient hospital, and nursing facility) II PRA_NOV2021_Template Changes_#13.xlsx 01/14/2022
Generic Supporting Statement GenIC #13 - Generic Supporting Statement (2022 version 7).docx 01/24/2022
Questions Logic III UPL Guidance Questions Logic_13.xlsx 01/24/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.