Information Collection

Payment Error Rate Measurement - State Medicaid and CHIP Eligibility

IC 46143 under ICR 201310-0938-003 · OMB 0938-1012.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1012 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10184 Payment Error Rate Measurement - State Medicaid and CHIP Eligibility	Form and Instruction
PETT_UserGuide_January2013.pdf	Instruction
CMS-10184 PERM Review Summary and Instructions PERM Review Summary and Instructions final.pdf	Form and Instruction

IC Title:

Payment Error Rate Measurement - State Medicaid and CHIP Eligibility

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10184	PERM Review Summary and Instructions	PERM Review Summary and Instructions final.pdf		Yes	Yes	Fillable Printable
Instruction			PETT_UserGuide_January2013.pdf		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 34

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 10 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	34	34
Annual IC Time Burden (Hours)	34,000	34,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.