Form CMS-10180 IBNR

CHIP Incurred but Not Reported (IBNR) Survey

I. CHIP ACCOUNTS PAYABLE

CHIP 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-64.21U, CMS-64.21 and the CMS- 21 for quarter ending as of the dates indicated below. (TOTAL = STATE + FEDERAL FINANCIAL PARTICIPATION (FFP))

	L atest CAFR (9/30/XX or prior) as of		Previous CAFR (9/30/XX or prior) as of
	Total (Whole dollars)	FFP (Whole dollars)	Total (Whole dollars)	FFP (Whole dollars)
1 - Total CHIP Accounts Payable 1
2 - Payments owed by the State for CHIP and Local Administrative Expenses
3 - Other Accounts Payable (define)
4 - Total Accounts Payable
5 - Recast of Prior Period Estimate (For example, what claims were paid in FYXX for previous FYXX.)

STATE ________________________ CONTACT PERSON

PHONE________________________ E-MAIL____________________________

ADDRESS _______________________________________________________________________________

CITY STATE ZIP_______________________

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 information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0988. The time required to complete this information collection is estimated to average 7 hours per survey, including the time to review instructions, searching 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, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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-10180

II. CHIP ACCOUNTS RECEIVABLE

CHIP 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‑64.21U, 64.21, and 21 for quarter ending as of the dates indicated below. (TOTAL = STATE + FEDERAL FINANCIAL PARTICIPATION, (FFP)).

Reporting Dates:	Latest CAFR (9/30/XX or prior) as of ___________		Previous CAFR (9/30/XX or prior) as of ___________
	Total (Whole dollars)	FFP (Whole dollars)	Total (Whole dollars)	FFP (Whole dollars)
1 - Total medical assistance accounts receivable
A - Overstated Claims
B - Drug Rebates
C - Other (define)
2 - Less: Allowance for Uncollectible Amount for Above Accounts
3 -Total Net Accounts Receivable
4 - Other Receivables not in CAFR (define)
5 - Total Accounts Receivable
6- Recast of Prior Period Estimate (For example, what claims were paid in FYXX for previous FYXX.)

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

III. AVERAGE DAYS

Please provide the average number of business days that elapse from when a service is provided to a CHIP beneficiary until the State reimburses the provider for the claim.

CMS-10180

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