Crosswalk for condensed forms(1) final

Revisions to Form CMS# 10184 (0938-1012) Payment Error Rate Measurement-State Medicaid and CHIP Eligibility
MONTHLY SAMPLE SELECTION, DETAILED ACTIVE CASE REVIEW FINDINGS SUBMISSION REPORT,
DETAILED NEGATIVE CASE REVIEW FINDINGS SUBMISSION REPORT, DETAILED PAYMENT REVIEW
FINDINGS SUBMISSION REPORT
Issue
#
1.

2.

Form

Section

Payment Error
Rate
Measurement
(PERM) – State
Medicaid and
CHIP Eligibility
CMS – 10184D
CMS – 10184A
CMS – 10184B

Action to be
performed
Electronic system
has changed from
PERT to PETT
Revise as follows

Changes to the Collection
Instrument

Replace with Payment Error
Rate Measurement (PERM)
Eligibility Reviews Summary
Findings

3.

State

Revise as follows

Replace with
A. State

4.

Date

Revise as follows

Replace with
B. Date

5.

Program

Revise as follows

Replace with
C. Program

6.

Sample Month
and Year

Revise as follows

Replace with
D. Sample Month & Year

Reason for the Change
Change in contractor, therefore
the electronic system used to
capture data has changed
Revised to reduce burden on the
state to use one collection
instrument to capture required
information – see attached
collection instrument

Revised for clarification purpose
Respondent using the upload
option can select the appropriate
state from the drop-down list
Revised for clarification purpose
Respondent using the upload
option this filed will populate after
the form is loaded
Revised for clarification purpose
Respondents using the upload
option can select the appropriate
program from the drop down list
Revised for clarification purpose
Respondent using the upload
option can select the sample
month and year from the drop
down list
1

Issue
#
7.

Form

Section
Number of cases
in universe that
month

Action to be
performed
Revise as follows

Changes to the Collection
Instrument
Replace with
E. Active Universe Total

Reason for the Change

Revised to reduce burden
on respondents, one form
used for all collection
information
Revised to reduce burden on
respondents, one form used for
all collection information

8.

Applications

Revise as follows

Replace with
E.1. Stratum 1 total ( if
applicable)

9.

Redetermination

Revise as follows

Replace with
E.2 Stratum 2 total (if
applicable)

10.

All Other Cases

Revise as follows

11.

Negative Cases

Revise as follows

Replace with
E.3. Stratum 3 total (if
applicable)
Replace with
F. Negative Universe Total

12.

Column 1

Revise as follows

Replace with
Case/Beneficiary ID

13.

Column 2

Revise as follows

Replace with
Eligibility Category

14.

Column 3

Revise as follows

Replace with
Universe

15.

Column 4

Revise as follows

Replace with
Stratum (if applicable)

Revised to reduce burden on
respondents, one form used for
all collection information

Revised to reduce burden on
respondents, one form used for
all collection information
Revised for clarification purpose
Respondent can use one form for
all collection information
Revised to reduce burden on
respondents, one form used for
all collection information
Revised for clarification of
information from respondent this
column added Using the upload
option the appropriate eligibility
category can be selected from the
drop down list
Revised to reduce burden on
respondents, one form used for
all collection information
Revised to reduce burden on
respondents, one form used for
all collection information
2

Issue Form
#
16.

Section
Column 5

Action to be
performed
Revise as follows

Changes to the Collection
Instrument
Replace with
Case Action

17.

Column 6

Revise as follows

Replace with
Review Month

18.

Column 7

Revise as follows

Replace with
Review Findings

19.

Column 8

Revise as follows

Replace with
Total Dollars

20.

Column 9

Revise as follows

Replace with
Total Dollars in Errors

21.

Column 10

Revise as follows

Replace with
Total Dollars Correct

22.

Column 11

Revise as follows

Replace with
Total Dollars Undetermined

23.

Column 12

Revise as follows

Replace with
Cause of Error

Reason for the Change
Added for clarification of
information from respondent.
Respondent would identify the
case action as Application,
Redetermination for active cases;
Denial or Termination for
Negative Cases
Revised to reduce burden on
respondents, one form used for
all collection information
Revised to reduce burden on
respondents, one form used for
all collection information
Revised to reduce burden on
respondents, one form used for
all collection information
Revised to reduce burden on
respondents, one form used for
all collection information
Revised to reduce burden on
respondents, one form used for
all collection information
Revised to reduce burden on
respondents, one form used for
all collection information
A drop down list of cause of
errors is available for the
respondents use on the electronic
system

3