Payment Error Rate Measurement - State Medicaid and CHIP Eligibility

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-10184 Payment Error Rate Measurement - State Medicaid and CHIP Eligibility Form
CMS-10184.PERM Form Instructions-10-30-06.DOC Instruction
CMS-10184 CMS-10184.FINAL-PERM Eligibility Error Rate Forms CMS-10184.FINAL-PERM Eligibility Error Rate Forms-10-30-06.doc Form

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10184	CMS-10184.FINAL-PERM Eligibility Error Rate Forms	CMS-10184.FINAL-PERM Eligibility Error Rate Forms-10-30-06.doc		Yes	No	Fillable Printable
Instruction			CMS-10184.PERM Form Instructions-10-30-06.DOC		Yes	No	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: 0 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	408	408
Annual IC Time Burden (Hours)	40,800	40,800
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.