Form CMS-10398 (#4) CMS-10398 (#4) RAC Phase III Reporting

PHASE III

S Audits Completed fields on one screen tate/Territory (Two-letter postal abbreviation)
Reporting Period (MM/DD/YYYY to MM/DD/YYYY)
Audits Completed
	Number of RAC audits completed during this reporting period, by provider type (For reporting purposes, an “audit” is a RAC financial review activity after which a provider will be notified of the results—such as through a demand letter to the provider, a notification that no demand letter will be issued, and/or a notification to the provider that an underpayment has been identified. Each such financial review activity should be reported as one “audit”. Report RAC audits as “complete” only if the provider has been notified of the audit results—such as through the issuance of a demand letter, notification that no demand letter will be issued, and/or notification that an underpayment has been identified.)
	Inpatient care (e.g. hospitals)
	Outpatient care (e.g. laboratory, X-rays, MRIs, CTs, diagnostics)
	Physician services (e.g. E&M codes, physician procedures, other professional services)
	Long-term care (e.g. nursing homes, mental health facilities, institutional care)
	Pharmacy (e.g. prescription drugs)
	All other provider types (e.g. dental, transportation, home health)
	Total number of RAC audits completed during this reporting period		This cell will auto-sum the values from above
	Total number of claims audited by a RAC during this reporting period (Report only claims for which the respective RAC audit was completed during this reporting period.)

Overpayments fields on one screen
Overpayments
	Overpayments Identified
	Dollar value of overpayments identified by a RAC during this reporting period, by provider type (The amount “identified” by any RAC should equal the amount that appears in the overpayment letter submitted to the provider.)
	Inpatient care (e.g. hospitals)
	Outpatient care (e.g. laboratory, X-rays, MRIs, CTs, diagnostics)
	Physician services (e.g. E&M codes, physician procedures, other professional services)
	Long-term care (e.g. nursing homes, mental health facilities, institutional care)
	Pharmacy (e.g. prescription drugs)
	All other provider types (e.g. dental, transportation, home health)
	Total dollar value of overpayments identified by a RAC during this reporting period			This cell will auto-sum the values from above
	Overpayment Notifications
	Total number of overpayment notifications made during this reporting period as a result of RAC audits
	(This number should reflect the number of overpayment letters that were issued to RAC-audited providers.)
	Overpayments Recovered
	Dollar value of RAC-identified overpayments recovered during this reporting period, by provider type (The amounts “recovered” should reflect dollars that were received by the State.)
	Inpatient care (e.g. hospitals)
	Outpatient care (e.g. laboratory, X-rays, MRIs, CTs, diagnostics)
	Physician services (e.g. E&M codes, physician procedures, other professional services)
	Long-term care (e.g. nursing homes, mental health facilities, institutional care)
	Pharmacy (e.g. prescription drugs)
	All other provider types (e.g. dental, transportation, home health)
	Total dollar value of RAC-identified overpayments recovered during this reporting period			This cell will auto-sum the values from above

U Underpayments fields on one screen nderpayments
	Underpayments Identified
	Dollar value of underpayments identified by a RAC during this reporting period, by provider type (The amount “identified” by any RAC should equal the amount that was stated in the underpayment notification submitted to the provider.)
	Inpatient care (e.g. hospitals)
	Outpatient care (e.g. laboratory, X-rays, MRIs, CTs, diagnostics)
	Physician services (e.g. E&M codes, physician procedures, other professional services)
	Long-term care (e.g. nursing homes, mental health facilities, institutional care)
	Pharmacy (e.g. prescription drugs)
	All other provider types (e.g. dental, transportation, home health)
	Total dollar value of underpayments identified by a RAC during this reporting period			This cell will auto-sum the values from above
	Underpayment Notifications
	Total number of underpayment notifications made during this reporting period as a result of RAC audits
	(This number should reflect the number of underpayment notifications that were issued to RAC-audited providers.)
	Underpayments Restored
	Dollar value of RAC-identified underpayments restored during this reporting period, by provider type (The amount “restored” should reflect dollars that were sent, credited, or otherwise transmitted to the respective provider.)
	Inpatient care (e.g. hospitals)
	Outpatient care (e.g. laboratory, X-rays, MRIs, CTs, diagnostics)
	Physician services (e.g. E&M codes, physician procedures, other professional services)
	Long-term care (e.g. nursing homes, mental health facilities, institutional care)
	Pharmacy (e.g. prescription drugs)
	All other provider types (e.g. dental, transportation, home health)
	Total dollar value of RAC-identified underpayments restored during this reporting period			This cell will auto-sum the values from above

Appeals
	Total number of RAC determinations for which an appeal was filed during this reporting period (Do not double-count any determinations that are appealed at more than one level within the State’s appeal process. Any determination that was appealed on at least the first level should be categorized as an appeal.)
	Total dollar amount associated with the appeals filed during this reporting period
	Total number of appeals determinations that were decided in the provider’s favor during this reporting period
	Total dollar amount that was overturned on appeal during this reporting period (Report all dollars that were overturned on appeal during this reporting period, regardless of whether the initial appeal was filed during this reporting period or during a previous reporting period.)
Other
	Total dollar amount of RAC administrative expenses incurred by the State during this reporting period (This dollar value should correlate with the RAC administrative expenses that were reported by the State on Line 27 of the CMS-64.10 forms that cover the same reporting period.)
	Number of suspected fraud referrals the State made to law enforcement during this reporting period, due to RAC input (In instances where a suspected fraud referral was recommended by multiple sources—such as hotline tips or other tips, in addition to the RAC contractor’s recommendation—report only the referrals for which the RAC contractor was the earliest source to notify the State that this referral be made.)

PRA 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 0938-1148. The time required to complete this information collection is estimated to average 20 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.

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