Payment Error Rate Measurement - State Medicaid and CHIP Eligibility (CMS-10184)

Forms and Documents

Document	Type	Status	Availability
Form CMS-10184 Corrective Action Report	Form	Modified	Available
Form CMS-10184 Summary of Eligibility and Payment Review Findings	Form and Instruction	Modified	Available
Form CMS-10184 Reporting Individual Payment Findings	Form	Modified	Repair queued
Form CMS-10184 Reporting Individual Review Findings	Form	Modified	Repair queued
Form CMS-10184 Review Findings	Form	Modified	Repair queued
Form CMS-10184 Monthly Sampling Lists	Form	Modified	Repair queued
Form CMS-10184 Reinstatement of Prior Burden Estimates for CMS-10184E	Form and Instruction	Modified	Repair queued
Form CMS-10184 Payment Error Rate Measurement - State Medicaid and CHIP Eligibility (MEQC Substitution)	Form and Instruction	Modified	Repair queued
CMS-10184.Supporting Statement Part B.docx	Supporting Statement B	Uploaded 2017-03-22	Repair queued
CMS 10184.Supporting Statement - Part A.doc	Supporting Statement A	Uploaded 2017-03-22	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
46149	Corrective Action Report	Form	Modified
46148	Summary of Eligibility and Payment Review Findings	Form and Instruction	Modified
46147	Reporting Individual Payment Findings	Form	Modified
46146	Reporting Individual Review Findings	Form	Modified
46145	Review Findings	Form	Modified
46144	Monthly Sampling Lists	Form	Modified
46143	Sampling Plan	Instruction	Modified
193769	Reinstatement of Prior Burden Estimates for CMS-10184E	Form and Instruction	Modified
190303	Payment Error Rate Measurement - State Medicaid and CHIP Eligibility (MEQC Substitution)	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1012	ICR Reference No: 201609-0938-031
Status: Historical Active	Previous ICR Reference No: 201310-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No: 20477
Title: Payment Error Rate Measurement - State Medicaid and CHIP Eligibility (CMS-10184)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/23/2017
	Date Received in OIRA: 10/03/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2020	36 Months From Approved	06/30/2017
Responses	1,583	0	1,583
Time Burden (Hours)	946,164	0	946,164
Cost Burden (Dollars)	0	0	0

---

Abstract: The Improper Payments Information Act (IPIA) of 2002 requires CMS to produce national error rates for Medicaid and SCHIP. To comply with the IPIA, CMS needs the information to be collected in order to provide some Federal overview of state eligibility determinations to ensure correctness and consistency among states and to use the State-specific error rates as the basis for calculating national eligibility error rates for Medicaid and SCHIP.

---

Authorizing Statute(s): PL: Pub.L. 107 - 300 2 Name of Law: The Improper Payments Information Act of 2002
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 20643	04/08/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 47805	07/22/2016
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 9

IC Title	Form No.	Form Name
Sampling Plan	CMS-10184	Monthly Sample Selection List
Monthly Sampling Lists	CMS-10184	Monthly Sample Selection List
Review Findings	CMS-10184	Monthly Sample Selection List
Reporting Individual Review Findings	CMS-10184, CMS-10184	Detailed Active Case Review Findings ,   Review Findings
Reporting Individual Payment Findings	CMS-10184	Detailed Payment Review Findings
Summary of Eligibility and Payment Review Findings	CMS-10184	Monthly Sample Selection List
Corrective Action Report	CMS-10184	Summary of Eligibility and Payment Review Findings
Payment Error Rate Measurement - State Medicaid and CHIP Eligibility (MEQC Substitution)	CMS-10184, CMS-10184	MEQC Substitution ,   MEQC substitution Detailed Case Review Findings
Reinstatement of Prior Burden Estimates for CMS-10184E	CMS-10184	MEQC substitution Summary of Findings

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,583	1,583	0	0	0	0
Annual Time Burden (Hours)	946,164	946,164	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/03/2016

---