Form CMS-301 Certification of Medicaid Eligibility Quality Control (M

OMB Approval #: 0938-0246

Certification of Medicaid Eligibility Quality Control (MEQC) Payment Error Rate

State: _________________________________________

Review Period: _________________________________

Sample

Size	Drops	Listed in Error

Stratum/Substratum

Medical 1-0

Assistance 1-1

Only 1-2 1-3

1-4

1-5

1-6

1-7

1-8

1-9

1-A

2-0

2-1

2-2

2-3

2-4

2-5

2-6

2-7

2-8

2-9

2-A

MEQC Payment Error Rate Lower Limit

I certify that this information is accurate and that we will maintain the sample case records

used in the calculation of this reported error rate and lower limit for a period of 3 years. I understand that this information may be used for Federal financial grant adjustment in accordance with 42 CFR 431.865 and that our sample case records and calculations are subject to Federal audit.

Signature: ______________________________ Date: _______________

State Medicaid Director or Designee

Please mail this form to your respective Centers for Medicare and Medicaid Services (CMS) regional office by the end of the first full week in December for the first six-month review period of the Federal fiscal year (October –March) and by the end of the first full week in June for the second six-month review period (April – September).

CMS-301

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 0938-0246. The time required to complete this information collection is estimated to average 441 annual hours per response for both reporting and recordkeeping purposes, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Reports Clearance Officer, Baltimore, Maryland 21244-1850. Lolower