CMS-R-199 Medicaid Incurred But Not Reported 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))
Latest CAFR (9/30/XX or
prior) as of

Previous CAFR (9/301XX
or prior) as of

Total

FFP

Total

FFP

(Whole dollars)

t\V"id~i'd..i$)

(Whole dollars)

~'• •M1

t - Total medical
assistance accounts
payable I

2 - Payments owed by the
State for Medicaid State
and local administrative
expenses
3 - Other accounts
payable (define)

STATE
PHONE

CONTACT PERSON
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 infonnation unless it displays a valid OMB control number. The valid OMB control number for this

infonnation 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 infonnation 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 (9/301XX or
prior) as of

Previous CAFR (9/30/XX
or prior) as of

Total

FFP

Total

FFP

(Whole dollars)

l\VItOle!iquars)

(Whole dollars)

(WIlDIe~

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)

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

III. AVERAGE DAYS
Please provide the average number of .l.~~!"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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