View Information Collection (IC)

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#24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs CMCS
 
Unchanged
 
Mandatory
 

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

Health Health Care Services

 

54 0
   
State, Local, and Tribal Governments
 
   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

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
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