Cms-10184

OMB Approval #

Payment Error Rate Measurement (PERM) Eligibility Reviews:

Cases Selected for Review: Monthly Sample Selection List

Due on the 15^th day of the month after the sample month and before the eligibility reviews begin.

Monthly Sample Selection List
A. State
B. Date
C. Program
D. Sample Month & Year
E. Number of cases in universe that month	Stratum 1 Applications	Stratum 2 Redeterminations	Stratum 3 All Other Cases	Negative Cases
F.	Case/Beneficiary Identification	Case/ Beneficiary Identification	Case/ Beneficiary Identification	Case/ Beneficiary Identification
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OMB Approval #

Payment Error Rate Measurement (PERM) Eligibility Reviews:

Detailed Review Findings for Active Case Reviews

Due within 150 days from the end of each sample month.

A. State
B. Date
C. Program
D. Sample Month & Year

E. Case ID	Review Month	Dropped Due to Beneficiary Fraud	Stratum 1,2 or 3	Review Finding E -eligible EI-eligible with ineligible services NE- not eligible U –undetermined L/O – liability overstated L/U - understated MCE1 – managed care error, ineligible for managed care MCE2 – eligible for managed care but improperly enrolled	Cause of Error, if known Example: excess income, non-resident.
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OMB Approval #

Payment Error Rate Measurement (PERM) Eligibility Reviews:

Detailed Findings for Negative Cases

Due within 150 days of the end of each sample month.

A. State
B. Date
C. Program
D. Sample Month and Year

E. Case/ Beneficiary ID	Denial or Termination D – denial T - termination	Review Finding C – correct ID – improper denial IT – improper termination	Cause of Error, if known
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OMB Approval #

Payment Error Rate Measurement (PERM) Eligibility Reviews:

Detailed Payment Review Findings

Due within 210 days of the end of each sample month.

A. State
B. Date
C. Program
D. Sample Month & Year

E. Case ID	Dropped Due to Beneficiary Fraud	Stratum 1,2 or 3	Review Finding E -eligible EI-eligible with ineligible services NE- not eligible U –undetermined L/O – liability overstated L/U - understated MCE1 – managed care error, ineligible for managed care MCE2 – eligible for managed care but improperly enrolled	Payment Amount Correct	Payment Amount in Error

OMB Approval #

Payment Error Rate Measurement (PERM) Eligibility Reviews:

Summary Findings and Error Rate Tables

Due July 1 following the Federal fiscal year being measured.

Summary Findings Table

A. State
B. Date
C. Program
	Number of Cases in Universe	Number of Cases Sampled	Number of Fraud Cases Excluded from the Universe or Sample	Number of Cases Eligible	Number of Cases Ineligible	Number of Cases Undetermined	Total Dollars Paid	Total Dollars Correct	Total Dollars in Error
D. Total
E. Active
Stratum 1
Stratum 2
Stratum 3
F. Negative
Denials
Terminations

Error Rate Table

	Dollar Amount	Error Rate	Confidence and Precision	Percentage
G. Active Payment Error Rate				N/A
H. Active Case Error Rate	N/A			N/A
I. Negative Case Error Rate	N/A			N/A
J. Undetermined Cases		N/A	N/A

I certify that this information is accurate and that the State will maintain the sampled case records used in the calculation of this reported error rate for a minimum period of three years. I understand that this information may be subject to Federal review and that our sampled case records and calculations are subject to Federal audit.

Signature: ______________________________ Date: _______________

State Medicaid/SCHIP Director or Designee

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-XXXX. The time required to complete this information collection is estimated to average 13,180 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.