Sampling Plan

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1012 can be found here:

Documents and Forms

Document Name Document Type
-CMS-10184.Instructions for Completing the PERM Monthly Sample Selection List.doc Instruction
CMS-10184 Monthly Sample Selection List -CMS-10184.Monthly Sample Selection List.doc Form

Information Collection (IC) Details

IC Title:	Sampling Plan	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			-CMS-10184.Instructions for Completing the PERM Monthly Sample Selection List.doc		Yes	No	Printable Only
Form	CMS-10184	Monthly Sample Selection List	-CMS-10184.Monthly Sample Selection List.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 34	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 10 %

	Approved	Previously Approved
Annual Number of Responses for this IC	34	34
Annual IC Time Burden (Hours)	34,000	34,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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