CMS-301 Certfication of Eligibility/Error Rate

OMB Approval #: 0938-0246
Certification of Medicaid Eligibility Quality Control Payment Error Rate
State:
Review Period:

Stratum/Substratum
Sample
Size

MEQC Payment Error Rate

Lower Limit

Drops

Listed in Error

I certify that this information is accurate and that we will maintain the sample case records used in the calculation of this reported error rate
and lower limit for a period of 3 years. I understand that this information may be used for Federal financial grant adjustment in accordance
with 42 CFR 431.865 and that our sample case records and calculations are subject to Federal audit.

Signature

Date:

Please mail this form to your respective Health Care Financing Administration regional office by the end of the first full week in December for
the first six month period of the Federal fiscal year (October through March), and by the end of the first full week in June for the second sixmonth review period (April through September).

CMS-301 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 for this information collection is 0938-0246. The time required to complete this information collection
is estimated to average 441 annual hours per response for both reporting and recordkeeping purposes, including the time to review
instructions, search existing data resources, gather the data needed and complete and review the information collection. If you have any
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security
Boulevard, Reports Clearance Officer, Baltimore, Maryland 21244-1850.