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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
GenIC #24 (Extension w/o change): Medicaid Accountability – UPL ICF/IID, Clinic Services, Medicaid Qualified Practitioner Services and Other Inpatient & Outpatient Facility Providers
Agency IC Tracking Number:
IC Status:
New
Obligation to Respond:
Mandatory
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Instruction
24 - I - ICFID instructions final.doc
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #24
II - Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/ID) UPL Guidance
24 - II - ICFID Guidance final.docx
Yes
Yes
Fillable Fileable
Instruction
24 - III - Clinic Instructions Final.doc
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #24
IV - Clinic Upper Payment Limit (UPL) Guidance
24 - IV - Clinic UPL Guidance final.docx
Yes
Yes
Fillable Fileable
Instruction
24 - V - ACR Narrative Instructions Final Draft Clean.docx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #24
Qualified Medicaid Practitioner Enhanced Payment and Average Commercial Rate (ACR) Supplemental Payment Demonstration Guidance
24 - VI - 4 4 Phys Review Guidance Web Version Final Draft Clean.docx
Yes
Yes
Fillable Fileable
Instruction
24 - VII - Other facility Instructions final.docx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #24
VIII - Other Inpatient and Outpatient Facility Provider Narrative Instruction
24 - VIII - Other Facility Guidance -Final.docx
Yes
Yes
Fillable Fileable
Form
CMS-10398 #24
UPL Physician Template
24 - X - UPL Physician Template.xlsx
Yes
Yes
Fillable Printable
Form
CMS-10398 #24
UPL Institute Mental Disease Template 1
24 - XI - UPL-Institute-Mental-Disease Template 1.xlsx
Yes
Yes
Fillable Fileable
Form
CMS-10398 #24
UPL Institute Mental Disease Template
24 - XI - UPL-Institute-Mental-Disease Template.xlsx
Yes
Yes
Fillable Fileable
Form
CMS-10398 #24
XII. Intermediate Care Facilitiy Template
24 - XII - UPL-Intermediate-Care-Facility Template.xlsx
Yes
Yes
Fillable Fileable
Form
CMS-10398 #24
XIII - UPL Psychiatric Residential Treatment Facility (PRTF) Template
24 - XIII - UPL-Psychiatric-Residential-Treatment-Facility Template.xlsx
Yes
Yes
Fillable Fileable
Form
CMS-10398 #24
XIV - Clinic Template
#24 - Mediciad UPL-Clinic Template.xlsx
Yes
Yes
Fillable Printable
Instruction
#24 - Medicaid UPL Clinic Guidance.docx
Yes
Yes
Fillable Fileable
Form
CMS-10398 #24
IX - Funding Questions
IX - Funding Questions.doc
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 %
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
56
0
56
0
0
0
Annual IC Time Burden (Hours)
2,240
0
2,240
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
#24 - Supporting Statement
24 - Final Supporting Statement Medicaid Accountability.docx
01/08/2018
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.