Form CMS-10184 PERM Review Summary and Instructions

Payment Error Rate Measurement (PERM) Eligibility Reviews
Summary Findings
Due: July 1 following the Federal fiscal year being measured.
Summary Findings Table
A. State
B. Date
C. Program
Number Number Number
of
of Cases of Cases
Cases in Sampled Dropped
Universe
from
Sample

Number
of
Cases
Correct

Number
of Cases
Incorrect

Number of
Cases
Undetermined

Total
Dollars
Paid

Total
Dollars
Correct

Total
Dollars
in Error

Total Dollars
Undetermined

D. Active
Stratum 1
Stratum 2
Stratum 3
E. Negative
Denials
Terminations
F. Totals
I certify that this information is accurate and that the State will maintain the sampled case records used in the calculation of the eligibility
error rate for a minimum period of three years from this date. I understand that this information may be subject to Federal review and
that our sampled case records are subject to Federal audit.
Signature: ____________________________________________

Date:_____________________________________

State Medicaid or CHIP 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 0938-1012. The time required to complete
this information collection is estimated to average 50 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.

INSTRUCTIONS FOR COMPLETING THE PERM ELIGIBILITY REVIEWS
SUMMARY FINDINGS
Purpose: The Summary Findings form provides summary case review information from the review of all cases in the monthly active
and negative case samples as well as the payment error data, as appropriate. This form provides comprehensive data for active cases
(total and for each of the three strata) and negative cases (total denials and terminations).
This form is due by July 1st following the fiscal year being measured (i.e. for States completing PERM eligibility reviews for fiscal year
2010, the summary report is due July 1st, 2011).
Line by Line Instructions
SUMMARY FINDINGS TABLE
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 the Summary Findings form is being submitted to CMS (e.g. July 1, 2010).
Line C: Program
Enter the program for which the Summary Findings form applies (e.g. Medicaid or CHIP).
Line D: Active
Enter the total number of active cases equal to the sum of Strata 1, 2 and 3. An active case is a case containing information on
beneficiaries who were enrolled in the program in the sample month.
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.
Enter the total number of active cases in Stratum 1, Applications, sampled for the fiscal year.
Stratum 2—Redeterminations: A case constitutes a “redetermination” for the sample month if the State took an action to continue
eligibility in the sample month based on a completed redetermination.

Enter the total number of active cases in Stratum 2, Redeterminations, sampled for the fiscal year.
Stratum 3—All Other Cases: All other cases (properly included in the universe but do not meet the Strata 1 or 2 criteria) that are on
the program in the sample month are placed in Stratum 3.
Enter the total number of active cases in Stratum 3, All Other Cases, sampled for the fiscal year.
Line E: Negative
A negative case is a case where a beneficiary completed an application for benefits and the State denied the application or who
completed the redetermination process but whose program benefits were terminated by the State.
Enter the total number of negative cases; equal to the sum of denials and terminations.
Denials—Denials occur when the State rejects a completed application for not meeting categorical and financial eligibility requirements.
Enter the total number of denials sampled for the fiscal year.
Terminations—Terminations occur when an existing beneficiary no longer meets eligibility requirements and the State took an action
to terminate program eligibility.
Enter the total number of terminations sampled for the fiscal year.
Line F: Totals
Enter the total number of cases in each column. For example, in column one, enter the total number of cases in the universe. In column
two, enter the total number of cases sampled in each stratum of the active cases and total number of cases sampled as denied and
terminated for negative cases. In column three, enter the number of cases dropped during the fiscal year based on the acceptable
reasons to drop a case, etc.
For each row, enter the appropriate numbers in each column as follows:
• Number of Cases in the Universe Column
Enter the number of cases in the universe subject to sampling for the months review throughout the fiscal year. These cells
should be left blank in the Denials and Terminations rows because this information is not collected.
• Number of Cases Sampled Column
Enter the number of cases sampled in each of the categories described in the rows.

• Number of Cases Dropped from Sample
Enter the number of cases excluded from the sample due to the acceptable reasons given in the PERM eligibility guidance in
each of the categories described in the rows. These should equal the number of dropped cases reported on the monthly Detailed
Active Case Review Findings forms.
• Number of Cases Correct Column
Enter the number of cases deemed to be correct through the PERM eligibility reviews in each of the categories described in the
rows.
These should equal the number of case reported on the Detailed Active Case Review Findings forms completed throughout the
fiscal year with findings of E-eligible, EI-eligible with ineligible services, L/O-liability overstated, L/U-liability understated, MCE1—
managed care error, ineligible for managed care, or MCE2-eligibile for managed care, but improperly enrolled.
Enter the number of denied and terminated cases found correct (code C for cases correctly denied and terminated) through the
negative case action reviews throughout the fiscal year as reported on the Detailed Negative Case Review Findings forms.
• Number of Cases Incorrect Column
Enter the number of cases deemed to be incorrect through the PERM eligibility review in each of the categories described in the
rows.
These should equal the number of cases reported on the Detailed Active Case Review Findings forms completed throughout the
fiscal year with a finding of NE-not eligible.
Enter the number of denied and terminated cases found incorrect through the negative case action reviews throughout the fiscal
year as reported on the Detailed Negative Case Review Findings forms (codes ID for improper denials and IT for improper
terminations).
• Number of Cases Undetermined Column
Enter the number of cases for which the State was unable to determine eligibility in each of the categories described in the rows.
These should equal the number of case reported on the Detailed Active Case Review Findings forms completed throughout the
fiscal year with findings of U-undetermined.

The cells should be left blank in the Negative, Denials and Terminations rows because, if no evidence exists to support a denial
or termination, the case is cited as an improper denial or termination.
• Total Dollars Paid Column
Enter the total dollars paid that corresponds with each of the categories described in the rows.
The cells should be left blank in the Negative, Denials, and Terminations rows because payment reviews are not completed for
negative case reviews.
• Total Dollars Correct Column
Enter the total dollars paid correctly that corresponds with each of the categories described in the rows.
The cells should be left blank in the Negative, Denials, and Terminations rows because payment reviews are not completed for
negative case reviews.
• Total Dollars in Error Column
Enter the total dollars paid in error that corresponds with each of the categories described in the rows.
The cells should be left blank in the Negative, Denials, and Terminations rows because payment reviews are not completed for
negative case reviews.
• Total Dollars Undetermined Column
Enter the total dollars associated with all cases cited as undetermined and corresponds with each of the categories described in
the rows.
The cells should be left blank in the in the Negative, Denials, and Terminations rows because payment reviews are not
completed for negative case reviews and undetermined cases are not associated with negative case reviews.