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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
#24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs
Agency IC Tracking Number:
CMCS
IC Status:
Unchanged
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
Form and Instruction
CMS-10398 #24
Standard Funding Questions
IV - Standard Funding Questions-24.docx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #24
MACFIN_clinic-services-template
VI MACFIN_clinic-services-template.xlsx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #24
MACFIN_intermediate-care-upl-template
VII MACFIN_intermediate-care-upl-template.xlsx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #24
MACFIN_mental-disease-upl-template
VIII MACFIN_mental-disease-upl-template.xlsx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #24
MACFIN_physician-upl-template
IX MACFIN_physician-upl-template.xlsx
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10398 #24
MACFIN_prtf-upl-template
X MACFIN_prtf-upl-template.xlsx
Yes
Yes
Fillable Fileable
Form
CMS-10398 #24
Guidance Questions_Master File_Clinic
XI UPL Guidance Questions_Master File_Clinic.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 #24
Guidance Questions_Master File_ICF IID
XII UPL Guidance Questions_Master File_ICF IID.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 #24
Guidance Questions_Master File_IMD
XIII UPL Guidance Questions_Master File_IMD.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 #24
Guidance Questions_Master File_Physician
XIV UPL Guidance Questions_Master File_Physician.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10398 #24
Guidance Questions_Master File_PRTF
XV UPL Guidance Questions_Master File_PRTF.pdf
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 %
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
54
0
0
0
0
54
Annual IC Time Burden (Hours)
5
0
0
0
0
5
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Crosswalk 1 of 2 (Changes in guidance and instructions documents: IMD, ICF IID, PRTF, Clinic, and Physician) and Crosswalk 2 of 2 (Standard Funding Questions)
I Crosswalk-Guidance-Instructions_PRA-24.xlsx
01/14/2022
Crosswalk for Templates: IMD, ICF IID, PRTF, Clinic, and Physician
II PRA_NOV2021_Template Changes Crosswalk_#24.xlsx
01/14/2022
Generic Supporting Statement
V 24 -Generic Supporting Statement (2022 version 3).docx
01/14/2022
Questions Logic
III UPL Guidance Questions Logic_24.xlsx
01/24/2022
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.