Form CMS-10184 Summary of Eligibility and Payment Review Findings

OMB Approval # 0938-1012

Expires:XX/XX/XXXX

Payment Error Rate Measurement (PERM)

Due July 1 following the Federal fiscal year being measured.

State
Date
Program
	Number of Cases in the Universe	Number of Cases Sampled	Number of Cases Excluded from the Universe or Sample due to Beneficiary Fraud	Number of Cases Eligible	Number of Cases Ineligible	Number of Cases Undetermined	Total Dollars Paid	Total Dollars in Error
Total
Active
Stratum 1
Stratum 2
Stratum 3
Negative
Denials
Terminations

	Dollar Amount	Error Rate	Confidence and Precision	Percentage
Active Payment Error Rate				N/A
Active Case Error Rate	N/A			N/A
Negative Case Error Rate	N/A			N/A
Undetermined Cases		N/A	N/A

I certify that this information is accurate and that the State will maintain the sampled case records used in the calculation of this reported error rate for a minimum period of three years. I understand that this information may be subject to Federal review and that our sampled case records and calculations are subject to Federal audit.

Signature: ______________________________ Date: _______________

State Medicaid/SCHIP Director or Designee

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 0938-1012.  The time required to complete this information collection is estimated to average [XX 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. *****CMS Disclaimer*****Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact

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