Form CMS-10184.FINAL-PE CMS-10184.FINAL-PERM_Eligibility_Error_Rate_Forms

Payment Error Rate Measurement - State Medicaid and CHIP Eligibility

CMS-10184.FINAL-PERM_Eligibility_Error_Rate_Forms-10-30-06

Reinstatement of Prior Burden Estimates for CMS-10184E

OMB: 0938-1012

Document [doc]
Download: doc | pdf

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.


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File Typeapplication/msword
File TitleCertification of Medicaid Eligibility Quality Control (MEQC) Payment Error Rate
AuthorCMS
Last Modified ByCMS
File Modified2006-10-30
File Created2006-10-30

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