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GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs CMCS
 
New
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction 24 - I - ICFID instructions final.docx Yes No Printable Only
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
Form and Instruction CMS-10398 #24 V. Clinic Upper Payment Limit (UPL) Guidance 24 - V - Clinic UPL Guidance final.docx Yes Yes Printable Only
Instruction 24 - VI -Medicaid Qual Prac-Phys Instructions Final.docx Yes No Printable Only
Form and Instruction CMS-10398 #24 VII. Medicaid Qualified Practitioner Services (Physician) UPL Guidance 24 - VII - Medicaid Qual Prac-Phys Guidance Final.docx Yes Yes Fillable Fileable
Instruction 24 - VIII - Other facility Instructions final- IMD-PRTF.docx Yes No Printable Only
Form and Instruction CMS-10398 #24 IX. Other Inpatient and Outpatient Facility Provider Narrative Instruction 24 - IX - Other Facility Guidance -Final- IMD-PRTF.docx Yes Yes Fillable Fileable
Instruction 24 - X - Standard Funding Questions.docx Yes Yes Fillable Fileable
Form CMS-10398 #24 XI. Medicaid Qualified Practitioner Services (Physician) Standard Template 24 - XI Medicaid Qualified Practitioner Services Standard Template.xlsx Yes Yes Fillable Fileable
Form CMS-10398 #24 XII. Institutes for Mental Diseases (IMD) Standard Template 24 - XII Institutes for Mental Diseases IMD Template.xlsx Yes Yes Fillable Fileable
Form CMS-10398 #24 XIII. Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) Standard Template 24 - XIII Intermediate Care Facilities ICFIID Template.xlsx Yes Yes Fillable Fileable
Form CMS-10398 #24 XIV. Psychiatric Residential Treatment Facility (PRTF) Standard Template 24 - XIV Psychiatric Residential Treatment Facility PRTF Template.xlsx Yes Yes Fillable Fileable
Form CMS-10398 #24 XV. Clinic Standard Template 24 - XV Clinic Standard Template.xlsx Yes Yes Fillable Fileable
Instruction 24 - III - Clinic Services Narrative Instructions- Nov 2020.docx Yes No Fillable Fileable
Form and Instruction CMS-10398 #24 IV. Guidance - Medicare Payment-Based Clinic UPL Demonstration 24 - IV - Guidance - Medicare Payment-Based Clinic UPL Demonstration-Nov 2020.docx 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 24 - Generic Supporting Statement 2021 version 4.docx 01/20/2021
Template Crosswalks - XI (Physician), XII (IMD), XIII (ICF/IID), XIV (PRTF), XV (Clinic) 24 - Crosswalk ICF-IMD-AcR-PRTF-Clinic.xlsx 01/20/2021
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.