Form CMS-10184D Detailed Payment Review Findings

INSTRUCTIONS FOR COMPLETING THE PERM ELIGIBILITY REVIEWS

DETAILED PAYMENT REVIEW FINDINGS

MEQC DATA SUBSTITUTION

Purpose: The Detailed Payment Review Findings form provides detailed payment review findings for all cases in each monthly sample. This form identifies the total dollars paid, the amount correctly paid, the amount paid in error and the amount paid for undetermined cases, for each case as appropriate, in the sample month.

This form is due 210 days from the end of the sample month (i.e. the payment review for the sample month of January is due on August 21, which is 210 days from January 31).

Line by Line Instructions

Line A: State

Enter the name of the State participating in the PERM program that is submitting this report. “State” refers to the 50 States and the District of Columbia. The Territories are excluded from the PERM program.

Line B: Date

Enter the date that the Detailed Payment Review Findings form is being submitted to CMS (e.g. June 15, 2010). If this form is being resubmitted, enter date of resubmission.

Line C: Program

Enter the program for which the Detailed Payment Review Findings form applies (e.g. Medicaid or CHIP).

Line D: Sample Month

Enter the month for which the sample was drawn from the universe. “Universe” refers to the total number of cases in the sample month. The case universe will be unique for each month.

Line E: Case/Beneficiary Identification (ID)

“Case” refers to an individual beneficiary, family unit, or assistance unit (AU). In this row, enter the case identification (ID) or beneficiary ID, whichever is the custom of the State that correlates with the case reported as sampled on the monthly sample selection list for the sample month.

Add rows if the number of cases in the active case sample for the month being reported exceeds the number of rows provided.

Note: Include all sample cases in this table, not just those with payment errors.

• Number of Individuals

Enter the number of individuals included in the sampled case.

• Date of Dropped Case

A State can only drop and replace a case from the PERM eligibility sample for the following reasons:

1. A case which should have been excluded from the sampling universe was inadvertently included in the universe and sampled, or

2. A case is found to be under active beneficiary fraud investigation.

“Active beneficiary fraud investigation” is defined as a beneficiary’s name has been referred to the State Fraud and Abuse Control or similar investigation unit and the unit is currently and actively pursuing an investigation to determine whether the beneficiary committed fraud.

States should exclude these cases from the universe. However, if a State cannot exclude these cases from the universe, the State can drop these cases if they appear in the sample.

Do not enter a Review Finding for dropped cases.

Other reasons for cases to be dropped from the MEQC review are not applicable for the PERM reviews, e.g. client cannot be located. If a potentially dropped case falls under the classification of an “undetermined” case, it must be reported as such.

• Stratum

Enter the number of the eligibility stratum for the case (e.g. Stratum 1). The strata are as follows:

• Stratum 1—Applications: A case constitutes an “application” for the sample month if the State took an action to grant eligibility in that month based on a completed application.

• Stratum 2—Redeterminations: A case constitutes a “redetermination” for the sampling month if the State took an action to continue eligibility in the sample month based on a completed redetermination.

• Stratum 3—All Other Cases: All other cases (properly included in the universe but do not meet the strata one or two criteria) that are on the program in the sample month are placed in stratum three.

• Review Finding

Enter the letter code for the review finding (e.g. MCE1) for each case. The eight review findings are defined as follows:

• E-Eligible: An individual beneficiary meets the State’s categorical and financial criteria for receipt of benefits under the program.

• EI- Eligible with ineligible services: An individual beneficiary meets the State’s categorical and financial criteria for receipt of benefits under the Medicaid or CHIP programs but was not eligible to receive particular services. An example of “eligible with ineligible services” would be a case where the beneficiary did not fully pay his share of cost. Another example would be a person eligible under the medically needy group who received services not provided to the medically needy group.

• NE-Not eligible: An individual beneficiary is receiving benefits under the program but does not meet the State’s categorical and financial criteria for the month eligibility is being verified.

• U-Undetermined: A beneficiary case subject to a Medicaid or CHIP eligibility review decision under PERM about which a definitive determination of eligibility could not be made.

• L/O-Liability overstated: The beneficiary paid too much toward his liability amount or cost of institutional care and the State paid too little. The amount in error is the amount of the State’s underpayment.

• L/U-Liability understated: Beneficiary paid too little toward his liability amount or cost of institutional care and the State paid too much. The amount in error is the amount of the State’s overpayment.

• MCE1-Managed care error, ineligible for managed care: Upon verification of residency and program eligibility, the beneficiary is enrolled in managed care but is not eligible for managed care.

• MCE2-Managed care error, eligible for managed care but improperly enrolled: Beneficiary is eligible for both the program and for managed care but not enrolled in the correct managed care plan as of the month eligibility is being verified.

Leave this column blank if a case is dropped or oversample cases are not used.

• Payment Amount Correct—A correct payment amount is a payment to a provider, insurer or managed care organization based on the beneficiary’s eligibility for the program and for the services received under the coverage group under which the beneficiary is eligible as defined in the State’s plan.

  • For FFS cases, enter the total amount of dollars paid for the beneficiary based on claims for services rendered at any time in the spend down period 9if appropriate) through the review month or are rendered in the sample month (for cases in stratum 3) which are paid by the end of the fourth month after the review month (or sample month for cases in stratum 3).

  • For managed care cases, enter the capitated amount paid for the case. All managed care payments made for coverage in the review month (for strata 1 and 2 cases) and the sample month (for stratum 3 cases) are included regardless of the actual payment date so long as the payment dates fall within the review month (for cases in strata 1 and 2) or sample month and are paid by the end of the fourth month after the review month or sample month. In some States, managed care payments are made to managed care organizations in the month before or the month following the month of coverage. Prospective payments for the sample month will be counted.

Enter the portion of the payments, in part or in whole as appropriate, that were correct for each sampled case. Do not enter payment amounts for cases that are dropped.

Place a zero in this column if there is no correct payment amount.

• Payment Amount in Error—Enter the amount of payment that is in error based on the beneficiaries’:

  • Ineligibility for services received,

  • Ineligibility for the program,

  • Liability overstated or understated,

  • Ineligibility for managed care, or

  • Eligibility for managed care but enrollment in the wrong managed care plan.

Enter the portion of the payment, in whole or in part, that was in error for each sampled case.

Place a zero in this column if there is no payment amount in error.

• Payment Amount Undetermined—Enter the amount of payment that is undetermined based on a case not having the verification necessary to make an eligibility determination. The total payment amount for an undetermined case must be placed in this column.

Place a zero in this column if the case is not undetermined.

PERM does not use thresholds to determine payment amounts in error. States must use actual payment amounts when reporting improper payments using MEQC data.

Leave payment columns blank if a case is dropped or oversample cases are not used.

Payment Error Rate Measurement (PERM) Eligibility Reviews:

Detailed Payment Review Findings

MEQC Data Substitution

Due within 210 days from the end of each sample month.

A. State
B. Date
C. Program
D. Sample Month
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