Information Collection

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

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10398 #13 #13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form and Instruction
Form CMS-10398 #13 #13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits	Form and Instruction
CMS-10398 #13 MACFIN_inpatient-upl-template V MACFIN_inpatient-upl-template.xlsx	Form and Instruction
CMS-10398 #13 MACFIN_inpatient-upl-template V MACFIN_inpatient-upl-template.xlsx	Form and Instruction
CMS-10398 #13 MACFIN_outpatient-upl-template VI MACFIN_outpatient-upl-template.xlsx	Form and Instruction
CMS-10398 #13 MACFIN_outpatient-upl-template VI MACFIN_outpatient-upl-template.xlsx	Form and Instruction
CMS-10398 #13 MACFIN_nursing-facility-upl-template VII MACFIN_nursing-facility-upl-template.xlsx	Form and Instruction
CMS-10398 #13 MACFIN_nursing-facility-upl-template VII MACFIN_nursing-facility-upl-template.xlsx	Form and Instruction
CMS-10398 #13 Guidance Questions: Inpatient VIII UPL Guidance Questions_Master File_Inpatient.pdf	Form
CMS-10398 #13 Guidance Questions: Inpatient VIII UPL Guidance Questions_Master File_Inpatient.pdf	Form
CMS-10398 #13 Guidance Questions: Nursing IX UPL Guidance Questions_Master File_Nursing Facility.pdf	Form
CMS-10398 #13 Guidance Questions: Nursing IX UPL Guidance Questions_Master File_Nursing Facility.pdf	Form
CMS-10398 #13 Guidance Questions: Outpatient X UPL Guidance Questions_Master File_Outpatient.pdf	Form
CMS-10398 #13 Guidance Questions: Outpatient X UPL Guidance Questions_Master File_Outpatient.pdf	Form
I Crosswalk-Guidance-Instructions_PRA-13.xlsx Crosswalk-Guidance-Instructions (inpatient hospital, outpatient hospital, and nursing facility)	IC Document
I Crosswalk-Guidance-Instructions_PRA-13.xlsx Crosswalk-Guidance-Instructions (inpatient hospital, outpatient hospital, and nursing facility)	IC Document
II PRA_NOV2021_Template Changes_#13.xlsx Template Crosswalk: (Templates: inpatient hospital, outpatient hospital, and nursing facility)	IC Document
II PRA_NOV2021_Template Changes_#13.xlsx Template Crosswalk: (Templates: inpatient hospital, outpatient hospital, and nursing facility)	IC Document
GenIC #13 - Generic Supporting Statement (2022 version 7).docx Generic Supporting Statement	IC Document
GenIC #13 - Generic Supporting Statement (2022 version 7).docx Generic Supporting Statement	IC Document
III UPL Guidance Questions Logic_13.xlsx Questions Logic	IC Document
III UPL Guidance Questions Logic_13.xlsx Questions Logic	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

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

Agency IC Tracking Number:

CMCS

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	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

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 54

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	54	54
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.