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GenIC #57 (Revision): Medicaid Section 1115 Substance Use Disorder (SUD) Demonstration: Monitoring Reports Documents and Templates

IC 252106 under ICR 202401-0938-016 · OMB 0938-1148.

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

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GenIC #57 (Revision): Medicaid Section 1115 Substance Use Disorder (SUD) Demonstration: Monitoring Reports Documents and Templates CMCS
 
Unchanged
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction SUD_MonProtocolInstr.v4.0_PRA.pdf Yes Yes Printable Only
Form CMS-10398 #57 Monitoring Protocol Template SUD_MonProtocolTemp.v4.0_PRA.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10398 #57 Monitoring Protocol Workbook SUD_MonProtocolWB.v6.0_PRA.xlsx Yes Yes Fillable Fileable
Instruction SUD_MonReportInstr.v4.0_PRA.pdf Yes Yes Printable Only
Form CMS-10398 #57 Monitoring Report Template SUD_MonReportTemp.v4.0_PRA.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10398 #57 Monitoring Report Workbook SUD_MonReportWB.v6.0_PRA.xlsx Yes Yes Fillable Fileable
Instruction Video - Downloading 1115 Demonstration Monitoring Report Templates.docx https://cvpcorp-1115pmda.adobeconnect.com/p4l83cvhhqda/ Yes No Printable Only

Health Health Care Services

 

35 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 596 0 0 0 0 596
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
Generic Supporting Statement 57 - Generic Supporting Statement (2022 version 6).docx 03/15/2022
Crosswalk: Monitoring Protocol Instructions SUD Crosswalk 2022_Monitoring Protocol Instructions.xlsx 03/15/2022
Crosswalk: Monitoring Protocol Template SUD Crosswalk 2022_Monitoring Protocol Template.xlsx 03/15/2022
Crosswalk: Monitoring Protocol Workbook SUD Crosswalk 2022_Monitoring Protocol Workbook.xlsx 03/15/2022
Crosswalk: Monitoring Report Instructions SUD Crosswalk 2022_Monitoring Report Instructions.xlsx 03/15/2022
Crosswalk: Monitoring Report Template SUD Crosswalk 2022_Monitoring Report Template.xlsx 03/15/2022
Crosswalk: Monitoring Report Workbook SUD Crosswalk 2022_Monitoring Report Workbook.xlsx 03/15/2022
SMDL #17-003 SMDL 17-003.pdf 03/15/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.