#20: Payment Error Rate Measurement (PERM) Pilot

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	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	Yes	Yes	Fillable Printable
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	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 %

	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

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.