Information Collection

#24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs

IC 251148 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⚠️ Notice: This information collection may be referencing outdated material.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 #24 #24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs	Form and Instruction
Form CMS-10398 #24 #24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs	Form and Instruction
CMS-10398 #24 Standard Funding Questions IV - Standard Funding Questions-24.docx	Form and Instruction
CMS-10398 #24 Standard Funding Questions IV - Standard Funding Questions-24.docx	Form and Instruction
CMS-10398 #24 MACFIN_clinic-services-template VI MACFIN_clinic-services-template.xlsx	Form and Instruction
CMS-10398 #24 MACFIN_clinic-services-template VI MACFIN_clinic-services-template.xlsx	Form and Instruction
CMS-10398 #24 MACFIN_intermediate-care-upl-template VII MACFIN_intermediate-care-upl-template.xlsx	Form and Instruction
CMS-10398 #24 MACFIN_intermediate-care-upl-template VII MACFIN_intermediate-care-upl-template.xlsx	Form and Instruction
CMS-10398 #24 MACFIN_mental-disease-upl-template VIII MACFIN_mental-disease-upl-template.xlsx	Form and Instruction
CMS-10398 #24 MACFIN_mental-disease-upl-template VIII MACFIN_mental-disease-upl-template.xlsx	Form and Instruction
CMS-10398 #24 MACFIN_physician-upl-template IX MACFIN_physician-upl-template.xlsx	Form and Instruction
CMS-10398 #24 MACFIN_physician-upl-template IX MACFIN_physician-upl-template.xlsx	Form and Instruction
CMS-10398 #24 MACFIN_prtf-upl-template X MACFIN_prtf-upl-template.xlsx	Form and Instruction
CMS-10398 #24 MACFIN_prtf-upl-template X MACFIN_prtf-upl-template.xlsx	Form and Instruction
CMS-10398 #24 Guidance Questions_Master File_Clinic XI UPL Guidance Questions_Master File_Clinic.pdf	Form
CMS-10398 #24 Guidance Questions_Master File_Clinic XI UPL Guidance Questions_Master File_Clinic.pdf	Form
CMS-10398 #24 Guidance Questions_Master File_ICF IID XII UPL Guidance Questions_Master File_ICF IID.pdf	Form
CMS-10398 #24 Guidance Questions_Master File_ICF IID XII UPL Guidance Questions_Master File_ICF IID.pdf	Form
CMS-10398 #24 Guidance Questions_Master File_IMD XIII UPL Guidance Questions_Master File_IMD.pdf	Form
CMS-10398 #24 Guidance Questions_Master File_IMD XIII UPL Guidance Questions_Master File_IMD.pdf	Form
CMS-10398 #24 Guidance Questions_Master File_Physician XIV UPL Guidance Questions_Master File_Physician.pdf	Form
CMS-10398 #24 Guidance Questions_Master File_Physician XIV UPL Guidance Questions_Master File_Physician.pdf	Form
CMS-10398 #24 Guidance Questions_Master File_PRTF XV UPL Guidance Questions_Master File_PRTF.pdf	Form
CMS-10398 #24 Guidance Questions_Master File_PRTF XV UPL Guidance Questions_Master File_PRTF.pdf	Form
I Crosswalk-Guidance-Instructions_PRA-24.xlsx Crosswalk 1 of 2 (Changes in guidance and instructions documents: IMD, ICF IID, PRTF, Clinic, and Physician) and Crosswalk 2 of	IC Document
I Crosswalk-Guidance-Instructions_PRA-24.xlsx Crosswalk 1 of 2 (Changes in guidance and instructions documents: IMD, ICF IID, PRTF, Clinic, and Physician) and Crosswalk 2 of	IC Document
II PRA_NOV2021_Template Changes Crosswalk_#24.xlsx Crosswalk for Templates: IMD, ICF IID, PRTF, Clinic, and Physician	IC Document
II PRA_NOV2021_Template Changes Crosswalk_#24.xlsx Crosswalk for Templates: IMD, ICF IID, PRTF, Clinic, and Physician	IC Document
V 24 -Generic Supporting Statement (2022 version 3).docx Generic Supporting Statement	IC Document
V 24 -Generic Supporting Statement (2022 version 3).docx Generic Supporting Statement	IC Document
III UPL Guidance Questions Logic_24.xlsx Questions Logic	IC Document
III UPL Guidance Questions Logic_24.xlsx Questions Logic	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

#24 (Revision): Medicaid Accountability â Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs

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 #24	Standard Funding Questions	IV - Standard Funding Questions-24.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #24	MACFIN_clinic-services-template	VI MACFIN_clinic-services-template.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #24	MACFIN_intermediate-care-upl-template	VII MACFIN_intermediate-care-upl-template.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #24	MACFIN_mental-disease-upl-template	VIII MACFIN_mental-disease-upl-template.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #24	MACFIN_physician-upl-template	IX MACFIN_physician-upl-template.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10398 #24	MACFIN_prtf-upl-template	X MACFIN_prtf-upl-template.xlsx	Yes	Yes	Fillable Fileable
Form	CMS-10398 #24	Guidance Questions_Master File_Clinic	XI UPL Guidance Questions_Master File_Clinic.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #24	Guidance Questions_Master File_ICF IID	XII UPL Guidance Questions_Master File_ICF IID.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #24	Guidance Questions_Master File_IMD	XIII UPL Guidance Questions_Master File_IMD.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #24	Guidance Questions_Master File_Physician	XIV UPL Guidance Questions_Master File_Physician.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10398 #24	Guidance Questions_Master File_PRTF	XV UPL Guidance Questions_Master File_PRTF.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 1 of 2 (Changes in guidance and instructions documents: IMD, ICF IID, PRTF, Clinic, and Physician) and Crosswalk 2 of 2 (Standard Funding Questions)	I Crosswalk-Guidance-Instructions_PRA-24.xlsx	01/14/2022
Crosswalk for Templates: IMD, ICF IID, PRTF, Clinic, and Physician	II PRA_NOV2021_Template Changes Crosswalk_#24.xlsx	01/14/2022
Generic Supporting Statement	V 24 -Generic Supporting Statement (2022 version 3).docx	01/14/2022
Questions Logic	III UPL Guidance Questions Logic_24.xlsx	01/24/2022

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.