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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
GenIC # 24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician ServicesICF/DD), PRTFs, and IMDs
Agency IC Tracking Number:
CMCS
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.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
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:
54
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
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
Documents for IC
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.