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CMS-R-266 - Spreadsheet (rev 11-212016)SG1-30 (rev PRA Statement).pdf
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PRA Disclosure Statement This information collection request is required by states to obtain
benefits. It provides for the collection of hospital specific DSH payment information as required by
section 1923(j)(1) of the Social Security Act (the Act). 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 0938-0746. The time required to complete this information collection is estimated to
average 22 hours 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 C4-2605, Baltimore, Maryland 21244-1850.
Hospital Name
Estimate of HospitalSpecific DSH Limit
Institute for Mental Disease
Out of State DSH Hospitals
OMB Approved # 0938-0746 Expires TBD
Medicaid I/P
Utilization Rate
Low-Income
Utilization Rate
State-Defined DSH
IP/OP Medicaid FFS IP/OP Medicaid MCO
Qualitification Criteria
Rate Payments
Payments
Supplemental /
Enhanced Medicaid
IP/OP Payments
Total Medicaid IP/OP
Payments
Total Cost of Care Medicaid IP/OP
Services
Total Medicaid
Uncompensated Care
Costs
Total Uninsured
IP/OP Revenue
Total Applicable
Section 1011 Payments
Total Cost of IP/OP
Care for Uninsured
Total Uninsured
Total Annual
IP/OP Uncompensated Uncompensated Care
Costs
Care Costs
Disproportionate
Share Hospital
Payments
Medicaid Provider
Number
Medicare Provider
Number
Total Hospital Cost
Field Name
Hospital Name
Estimate of Hospital Specific DSH limit
Medicaid Inpatient Utilization Rate
Low Income Utilization Rate
State Defined DSH Qualification Criteria
IP/OP Medicaid FFS Basic Rate Payments
IP/OP Medicaid MCO Payments
Supplemental/Enhanced Medicaid IP/OP
Payments
Total Medicaid IP/OP Payments
Total Cost of Care for Medicaid IP/OP Services
Total Medicaid Uncompensated Care
Uninsured IP/OP Revenue
Total Applicable Section 1011 Payments
Total Cost of IP/OP Care for the Uninsured
Total Uninsured IP/OP Uncompensated Care
Costs
Total Annual Uncompensated Care Costs
Disproportionate Share Hospital Payments
Medicaid Provider Number
Medicare Provider Number
Total Hospital Cost
Financial Impact of Audit Findings
Field format
Field format
description
In-state field
Designation
Institute for Mental Disease field
Designation
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Out of State field
Designation
Alphanumeric
Numeric
Percentage
Percentage
Alphanumeric
Numeric
Numeric
Numeric
Text/Alphanumeric
Amount
Proportion/Amount
Proportion/Amount
Text/Alphanumeric
Amount
Amount
Amount
Numeric
Numeric
Amount
Amount
Required
Required
Required
Required
Required
Optional
Numeric
Numeric
Numeric
Numeric
Numeric
Amount
Amount
Amount
Amount
Amount
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Optional
Optional
Optional
Optional
Optional
Numeric
Numeric
Alphanumeric
Alphanumeric
Numeric
Numeric
Amount
Amount
Alphanumeric
Alphanumeric
Amount
Amount
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Optional
Required
Required
Required
Optional
Optional
Required
Required
Required
Required
Required
Required
Optional
Required
| File Type | application/pdf |
| Author | HCFA Software Control |
| File Modified | 2024-04-03 |
| File Created | 2024-04-03 |