Document
Certification of Medicaid Eligibility Quality Control (MEQC) Payment Error Rate
ICR 200908-0938-004 · OMB 0938-1012 · Object 13084701.
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Document Metadata
| File Type | application/msword |
|---|---|
| File Title | Certification of Medicaid Eligibility Quality Control (MEQC) Payment Error Rate |
| Author | CMS |
| Last Modified By | Writer |
| File Modified | 2006-10-30 |
| File Created | 2026-11-15 |
| Conversion State | complete |
Extracted Text
OMB Approval #
Payment Error Rate Measurement (PERM)
Due on the 15th day of the month after the sample month and before the eligibility reviews begin.
Monthly Sample Selection List
State
Date
Program
Sample Month and Year
Stratum 1 Applications
Stratum 2 Redeterminations
Stratum 3
All Other Cases
Negative Cases
Number of cases in universe that month
Case/Beneficiary ID
Case/ Beneficiary ID
Case/ Beneficiary ID
Case/ Beneficiary ID
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OMB Approval #
Payment Error Rate Measurement (PERM)
Due within 150 days from the end of each sample month.
Detailed Active Case Review Findings
State
Date
Program
Sample Month and Year
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)
Due within 150 days of the end of each sample month.
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)
Due within 210 days of the end of each sample month.
Detailed Payment Review Findings
State
Date
Program
Sample Month and Year
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)
Due July 1 following the Federal fiscal year being measured.
State
Date
Program
Number of Cases in the Universe
Number of Cases Sampled
Number of Cases Excluded from the Universe or Sample due to Beneficiary Fraud
Number of Cases Eligible
Number of Cases
Ineligible
Number of Cases Undetermined
Total Dollars Paid
Total Dollars in Error
Total
Active
Stratum 1
Stratum 2
Stratum 3
Negative
Denials
Terminations
Dollar Amount
Error Rate
Confidence and Precision
Percentage
Active Payment Error Rate
N/A
Active Case Error Rate
N/A
N/A
Negative Case Error Rate
N/A
N/A
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.