Form CMS-R-199 MEDICAID INCURRED BUT NOT REPORTED (IBNR) SURVEY

Medicaid Incurred but Not Reported (IBNR) Survey

I. MEDICAID ACCOUNTS PAYABLE

Medicaid amounts owed by the State to providers for services rendered and for State and local administrative expenses as of the dates indicated below, but excluding amounts paid and reported on the CMS-64 for quarter ending as of the dates indicated below. (TOTAL = STATE + FEDERAL FINANCIAL PARTICIPATION (FFP))

	L atest CAFR (9/30/XX or prior) as of		Previous CAFR (9/30/XX or prior) as of
	Total (Whole dollars)	FFP (Whole dollars)	Total (Whole dollars)	FFP (Whole dollars)
1 - Total medical assistance accounts payable 1
2 - Payments owed by the State for Medicaid State and local administrative expenses
3 - Other accounts payable (define)
4 – Total Accounts Payable

STATE ________________________ CONTACT PERSON

PHONE________________________ FAX ____________________________

ADDRESS _______________________________________________________________________________

I hereby certify that I have examined the data reported for the periods ending as indicated above, and that to the best of my knowledge and belief, it is based on and in agreement with, amounts verified by the State Auditor.

Signature ___________________________________

Name (Printed) _______________________________

Title Date ______________________

Disclosure Statement: 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 0938-0697. The time required to complete this information collection is estimated to average 3 hours per response, including the time to review instructions, searching 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, P.O. Box 26684, Baltimore, Maryland 21244 and to the Office of the Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

¹ Includes Claims incurred by Providers - not yet submitted to the State, Claims submitted by Providers - not yet processed or paid by the State, Cost report settlements, and Provider underpayments

CMS-R199

II. MEDICAID ACCOUNTS RECEIVABLE

Medicaid amounts owed to the State from various sources excluding the Federal Government as of the dates indicated below, but excluding amounts received and reported on the CMS‑64 for quarter ending as of the dates indicated below. (TOTAL = STATE + FEDERAL FINANCIAL PARTICIPATION, (FFP)).

Reporting Dates:	Latest CAFR (9/30/04 or prior) as of ___________		Previous CAFR (9/30/03 or prior) as of ___________
	Total (Whole dollars)	FFP (Whole dollars)	Total (Whole dollars)	FFP (Whole dollars)
1 - Total medical assistance accounts receivable
A - Third Party Liability
B - Probate Court Cases
C - Fraud and Abuse Cases
D - Provider Overpayments
E - Audits of annual cost reports
F - Drug Rebates
G - Other (define)
2 - Less: Allowance for Uncollectible Amount for Above Accounts
3 -Total Net Accounts Receivable
4 - Other Receivables not in CAFR (define)
5 - Total Accounts Receivable

Please attach a brief description of how the above payable and receivable amounts were computed.

III. AVERAGE DAYS

Please provide the average number of business days that elapse from when a service is provided to a Medicaid beneficiary until the State reimburses the provider for the claim.

CMS-R199

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