Cms-10180 Chip Incurred But Not Reported (ibnr) Survey

CHIP INCURRED BUT NOT REPORTED (IBNR) SURVEY
I. CHIP ACCOUNTS PAYABLE
CHIP amounts owed by the State to providers for services rendered and for State and local administrative expenses
as of the dates indicated below, but excluding amounts paid and reported on the CMS-64.21U, CMS-64.21 and the
CMS- 21 for quarter ending as of the dates indicated below. (TOTAL = STATE + FEDERAL FINANCIAL
PARTICIPATION (FFP))
Latest CAFR (9/30/XX or
prior) as of______________

Previous CAFR (9/30/XX
or prior) as of____________

Total

FFP

Total

FFP

(Whole dollars)

(Whole dollars)

(Whole dollars)

(Whole dollars)

1 - Total CHIP Accounts
Payable 1
2 - Payments owed by the
State for CHIP and Local
Administrative Expenses
3 - Other Accounts
Payable (define)
4 - Total Accounts Payable
5 - Recast of Prior Period
Estimate (For example,
what claims were paid this
FY for last FY.)
STATE ________________________ CONTACT PERSON
PHONE________________________ E-MAIL____________________________
ADDRESS _______________________________________________________________________________
CITY__________________________ STATE_______________________ ZIP_______________________
I hereby certify that I have examined the data reported for the periods ending as indicated above, and that to
the best of my knowledge and belief, it is based on and in agreement with, amounts verified by the State
Auditor.
Signature ___________________________________
Name (Printed) _______________________________
Title _________________________________________________ Date ______________________
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
0938-0988. The time required to complete this information collection is estimated to average 7 hours per survey, including the
time to review instructions, searching existing data resources, gather the data needed and complete and review the information
collection. If you have any 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.
1 Includes Claims incurred by Providers - not yet submitted to the State, Claims submitted by Providers - not yet processed or
paid by the State, Cost report settlements, and Provider underpayments

CMS-10180
OMB No. 0938-0988|Expiration Date: 05/31/2020 |Paperwork Reduction Act

II. CHIP ACCOUNTS RECEIVABLE
CHIP amounts owed to the State from various sources excluding the Federal Government as of the dates indicated
below, but excluding amounts received and reported on the CMS-64.21U, 64.21, and 21 for quarter ending as of the
dates indicated below. (TOTAL = STATE + FEDERAL FINANCIAL PARTICIPATION, (FFP)).
Reporting Dates:

Latest CAFR (9/30/XX or
prior) as of ___________

Previous CAFR (9/30/XX
or prior) as of ___________

Total

FFP

Total

FFP

(Whole dollars)

(Whole dollars)

(Whole dollars)

(Whole dollars)

1 - Total medical
assistance accounts
receivable
A - Overstated Claims
B - Drug Rebates
C - Other (define)
2 - Less: Allowance for
Uncollectible Amount for
Above Accounts
3 -Total Net Accounts
Receivable
4 - Other Receivables not
in CAFR (define)
5 - Total Accounts
Receivable
6- Recast of Prior Period
Estimate (For example,
what claims were paid this
FY for last FY.)
Please attach a brief description of how the above payable and receivable amounts were computed.

III. AVERAGE DAYS
Please provide the average number of business days that elapse from when a service is provided to a CHIP
beneficiary until the State reimburses the provider for the claim.
CMS-10180

OMB No. 0938-0988|Expiration Date: 05/31/2020 |Paperwork Reduction Act