Information Collection

#20: Payment Error Rate Measurement (PERM) Pilot

IC 214321 under ICR 201410-0938-016 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10398 (#20) #20: Payment Error Rate Measurement (PERM) Pilot	Form and Instruction
StateHealthOfficialLetter (3).pdf	Other-SHO Letter
CMS-10398 (#20) CMS PERM – PETT 2.0 Round 1 Pilot Findings Submission User Guide Round 1 Findings Submission [rev 9-11-2014 by OSORA PRA].docx	Form and Instruction
CMS-10398 (#20) CMS PERM – PETT 2.0 Round 2 Pilot Proposal Submission User Guide Round 2 Proposal Submission [rev 9-11-2014 by OSORA PRA].docx	Form and Instruction
#20 Supporting Statement - PERM Pilot Rounds 1 and 2 [Dec 2014].docx #20 Supporting Statement: Payment Error Rate Measurement (PERM) Pilot	IC Document

IC Title:

#20: Payment Error Rate Measurement (PERM) Pilot

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10398 (#20)	CMS PERM â PETT 2.0 Round 1 Pilot Findings Submission	User Guide Round 1 Findings Submission [rev 9-11-2014 by OSORA PRA].docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10398 (#20)	CMS PERM â PETT 2.0 Round 2 Pilot Proposal Submission	User Guide Round 2 Proposal Submission [rev 9-11-2014 by OSORA PRA].docx	Yes	Yes	Fillable Printable
Other-SHO Letter			StateHealthOfficialLetter (3).pdf	No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 52

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	52	52
Annual IC Time Burden (Hours)	1,120	1,120
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
#20 Supporting Statement: Payment Error Rate Measurement (PERM) Pilot	#20 Supporting Statement - PERM Pilot Rounds 1 and 2 [Dec 2014].docx	12/23/2014

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