Payment Error Rate Measurement - State Medicaid and CHIP Eligibility

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10184 CMS-10184.FINAL-PERM Eligibility Error Rate Forms	Form	Modified	Available
Form CMS-10184 CMS-10184.FINAL-PERM Eligibility Error Rate Forms	Form	Modified	Repair queued
Form CMS-10184 CMS-10184.FINAL-PERM Eligibility Error Rate Forms	Form and Instruction	Modified	Available
Form CMS-10184 CMS-10184.FINAL-PERM Eligibility Error Rate Forms	Form	Modified	Repair queued
Form CMS-10184 CMS-10184.FINAL-PERM Eligibility Error Rate Forms	Form	Modified	Repair queued
Form CMS-10184 CMS-10184.FINAL-PERM Eligibility Error Rate Forms	Form	Modified	Available
Form CMS-10184 CMS-10184.FINAL-PERM Eligibility Error Rate Forms	Form	Modified	Available
Form CMS-10184E Summary Findings	Form and Instruction	New	Available
Form CMS-10184B Detailed Active Case Review Findings	Form and Instruction	New	Available
Form CMS-10184A Cases Selected for Review: Monthly Sample Selection List	Form and Instruction	New	Available
Form CMS-10184D Detailed Payment Review Findings	Form and Instruction	New	Available
CMS-10184.Supporting Statement Part B.doc	Supporting Statement B	Uploaded 2009-08-07	Available
CMS-10184 (0938-1012) Final-Emergency Justification 7-8-09.doc	Supplementary Document	Uploaded 2009-08-07	Repair queued
CMS 10184.Supporting Statement - Part A -FINAL.doc	Supporting Statement A	Uploaded 2009-08-07	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
46149	Payment Error Rate Measurement - State Medicaid and CHIP Eligibility	Form	Modified	CMS-10184.FINAL-PERM Eligibility Error Rate Forms
46149	Payment Error Rate Measurement - State Medicaid and CHIP Eligibility	Instruction	Modified
46148	Payment Error Rate Measurement - State Medicaid and CHIP Eligibility	Form	Modified	CMS-10184.FINAL-PERM Eligibility Error Rate Forms
46148	Payment Error Rate Measurement - State Medicaid and CHIP Eligibility	Instruction	Modified
46147	Payment Error Rate Measurement - State Medicaid and CHIP Eligibility	Form and Instruction	Modified	CMS-10184.FINAL-PERM Eligibility Error Rate Forms
46147	Payment Error Rate Measurement - State Medicaid and CHIP Eligibility	Instruction	Modified
46146	Payment Error Rate Measurement - State Medicaid and CHIP Eligibility	Form	Modified	CMS-10184.FINAL-PERM Eligibility Error Rate Forms
46146	Payment Error Rate Measurement - State Medicaid and CHIP Eligibility	Instruction	Modified
46145	Payment Error Rate Measurement - State Medicaid and CHIP Eligibility	Form	Modified	CMS-10184.FINAL-PERM Eligibility Error Rate Forms
46145	Payment Error Rate Measurement - State Medicaid and CHIP Eligibility	Instruction	Modified
46144	Payment Error Rate Measurement - State Medicaid and CHIP Eligibility	Form	Modified	CMS-10184.FINAL-PERM Eligibility Error Rate Forms
46144	Payment Error Rate Measurement - State Medicaid and CHIP Eligibility	Instruction	Modified
46143	Payment Error Rate Measurement - State Medicaid and CHIP Eligibility	Form	Modified	CMS-10184.FINAL-PERM Eligibility Error Rate Forms
46143	Payment Error Rate Measurement - State Medicaid and CHIP Eligibility	Instruction	Modified
190303	Payment Error Rate Measurement - State Medicaid and CHIP Eligibility (MEQC Substitution)	Form and Instruction	New	Summary Findings
190303	Payment Error Rate Measurement - State Medicaid and CHIP Eligibility (MEQC Substitution)	Form and Instruction	New	Detailed Active Case Review Findings
190303	Payment Error Rate Measurement - State Medicaid and CHIP Eligibility (MEQC Substitution)	Form and Instruction	New	Cases Selected for Review: Monthly Sample Selection List
190303	Payment Error Rate Measurement - State Medicaid and CHIP Eligibility (MEQC Substitution)	Form and Instruction	New	Detailed Payment Review Findings

ICR Details

OMB Control No: 0938-1012	ICR Reference No: 200908-0938-004
Status: Historical Active	Previous ICR Reference No: 200810-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Payment Error Rate Measurement - State Medicaid and CHIP Eligibility
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 08/21/2009
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/18/2009
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/12/2009
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2010	01/31/2010	01/31/2010
Responses	1,379	0	1,360
Time Burden (Hours)	942,764	0	535,670
Cost Burden (Dollars)	0	0	0

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Abstract: The Improper Payments Information Act (IPIA) of 2002 requires CMS to produce national error rates for Medicaid and SCHIP. To comply with the IPIA, CMS needs the information to be collected in order to provide some Federal overview of state eligibility determinations to ensure correctness and consistency among states and to use the State-specific error rates as the basis for calculating national eligibility error rates for Medicaid and SCHIP.

Emergency Justfication: See Attached Emergency Justification that was approved by OMB.

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Authorizing Statute(s): PL: Pub.L. 107 - 300 2 Name of Law: The Improper Payments Information Act of 2002
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 3 601 Name of Law: Children's Health Insurance Program Reauthorization Act of 2009

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 36718	07/24/2009
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
Payment Error Rate Measurement - State Medicaid and CHIP Eligibility	CMS-10184	CMS-10184.FINAL-PERM Eligibility Error Rate Forms
Payment Error Rate Measurement - State Medicaid and CHIP Eligibility	CMS-10184	CMS-10184.FINAL-PERM Eligibility Error Rate Forms
Payment Error Rate Measurement - State Medicaid and CHIP Eligibility	CMS-10184	CMS-10184.FINAL-PERM Eligibility Error Rate Forms
Payment Error Rate Measurement - State Medicaid and CHIP Eligibility	CMS-10184	CMS-10184.FINAL-PERM Eligibility Error Rate Forms
Payment Error Rate Measurement - State Medicaid and CHIP Eligibility	CMS-10184	CMS-10184.FINAL-PERM Eligibility Error Rate Forms
Payment Error Rate Measurement - State Medicaid and CHIP Eligibility	CMS-10184	CMS-10184.FINAL-PERM Eligibility Error Rate Forms
Payment Error Rate Measurement - State Medicaid and CHIP Eligibility	CMS-10184	CMS-10184.FINAL-PERM Eligibility Error Rate Forms
Payment Error Rate Measurement - State Medicaid and CHIP Eligibility (MEQC Substitution)	CMS-10184D, CMS-10184A, CMS-10184B, CMS-10184E	Detailed Payment Review Findings ,   Cases Selected for Review: Monthly Sample Selection List ,   Detailed Active Case Review Findings ,   Summary Findings

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,379	1,360	19	0	0	0
Annual Time Burden (Hours)	942,764	535,670	407,094	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Please see the attached supporting statement.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/12/2009

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