Information Collection

GenIC #66 Revised (Eligibility Processing Data Report)

IC 281677 under ICR 202610-0938-013 · OMB 0938-1148.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form GenIC #66 Eligibility Processing Reports Portal Screen Shots GenIC #66 Revised (Eligibility Processing Data Report)	Form and Instruction
Form GenIC #66 Data portal GenIC #66 Revised (Eligibility Processing Data Report)	Form and Instruction
Form GenIC #66 Unwinding Eligibility and Enrollment Data Reporting Template GenIC #66 Revised (Eligibility Processing Data Report)	Form and Instruction
Eligibility Processing Data Specs June 2026_Clean.docx	Other-Eligibility Processing Data Re
Eligibility Processing Data Report Instrument Metrics Clean.docx	Other-Data Report Instrument Metrics
sho24002.pdf	Other-SHO# 24-002
GenIC #66 Eligibility Processing Reports Portal Screen Shots Medicaid and CHIP Eligibility Process Data Portal.pdf	Form and Instruction
GenIC #66 Data portal Medicaid and CHIP Eligibility Process Data Portal.pdf	Form and Instruction
GenIC #66 Unwinding Eligibility and Enrollment Data Reporting Temp unwinding-data-rprt .pdf	Form and Instruction
EP Data Screenshots and Mockups_Tracked.docx Redline - Eligibility Processing Reports Portal Screen Shots	IC Document
Eligibility Processing Data Specs June 2026_Tracked Changes.docx Redline - Eligibility Processing Data Report Specifications	IC Document
Eligibility Processing Data Report Instrument Metrics Redline.docx Redline - Data Report Instrument Metrics	IC Document
Eligibiltiy Processing Data Report Crosswalk C-E Data Collection.xlsx Crosswalk - Data Report	IC Document
GenIC 66 - Generic Supporting Statement (CMS-2454-IFC version 11).docx Generic Supporting Statement	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

GenIC #66 Revised (Eligibility Processing Data Report)

Agency IC Tracking Number:

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	GenIC #66	Yes	Yes	Fillable Fileable
Other-Eligibility Processing Data Report Specifications		Yes	No	Printable Only
Other-Data Report Instrument Metrics		Yes	No	Printable Only
Other-SHO# 24-002		No		Printable Only
Form and Instruction	GenIC #66	Yes	Yes	Fillable Fileable
Form and Instruction	GenIC #66	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: 56

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	2,388	2,388
Annual IC Time Burden (Hours)	8,872	8,872
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Redline - Eligibility Processing Reports Portal Screen Shots		07/28/2026
Redline - Eligibility Processing Data Report Specifications		07/28/2026
Redline - Data Report Instrument Metrics		07/28/2026
Crosswalk - Data Report		07/28/2026
Generic Supporting Statement		07/28/2026

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].