View Information Collection (IC)

View Information Collection (IC)

GenIC #13 (Revision): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits CMCS
 
New
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction 13 - Attachment A - NF Instructions.docx Yes No Printable Only
Form and Instruction CMS-10398 #13 Attachment B – Nursing Facility UPL Guidance 13 - Attachment B - NF Guidance.docx Yes Yes Fillable Fileable
Instruction 13 - Attachment C - OP Instructions-NOV-2020.docx Yes No Printable Only
Form and Instruction CMS-10398 #13 Attachment D – Outpatient Hospital UPL Guidance 13 - Attachment D - OP Guidance-NOV-2020.docx Yes Yes Fillable Printable
Instruction 13 - Attachment E - IP Instructions.docx Yes No Printable Only
Form and Instruction CMS-10398 #13 Attachment F – Inpatient Hospital UPL Guidance 13 - Attachment F - IP Guidance.docx Yes Yes Fillable Printable
Form CMS-10398 #13 Attachment G – Nursing Facility Standard Template 13 - Attachment-G-nursing-facility-upl-template.xlsx Yes Yes Fillable Printable
Form CMS-10398 #13 Attachment H – Outpatient Hospital Standard Template 13 - Attachment-H-outpatient-upl-template.xlsx Yes Yes Fillable Printable
Form CMS-10398 #13 Attachment I – Inpatient Hospital Standard Template 13 - Attachment-I-inpatient-hospital-upl-template.xlsx Yes Yes Fillable Fileable

Health Health Care Services

 

54 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved 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 54 0 54 0 0 0
Annual IC Time Burden (Hours) 5 0 5 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Generic Supporting Statement GenIC 13 -Supporting Statement 2021 version 6.docx 01/19/2021
Crosswalks - Attachments G (Nursing Facility), H (Outpatient Hospital), and I (Inpatient Hospital) 13 - Crosswalk_Nov-2020-IP-OP-NF.xlsx 01/19/2021
Crosswalk: Attachment C – Outpatient Hospital Narrative Instructions Crosswalk_C.xlsx 01/19/2021
Crosswalk: Attachment D – Outpatient Hospital UPL Guidance Crosswalk_D.xlsx 01/19/2021
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.