Form CMS-R-199 MEDICAID INCURRED BUT NOT REPORTED (IBNR) SURVEY

MEDICAID INCURRED BUT NOT REPORTED (IBNR) SURVEY
I. MEDICAID ACCOUNTS PAYABLE
Medicaid 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 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___________

Sources:

Total

FFP

Total

FFP

(Whole dollars)

(Whole dollars)

(Whole dollars)

(Whole dollars)

1 – Total medical
assistance accounts
payable1
2 – Payments owed by the
State for Medicaid State
and local administrative
expenses
3 – Other accounts
payable
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 0938-0697. 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.

CMS-R199
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

OMB No. 0938-0697| Expiration Date: 01/31/2020

|Paperwork Reduction Act

II. MEDICAID ACCOUNTS RECEIVABLE
Medicaid 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 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 ___________

Sources:

Total

FFP

Total

FFP

(Whole dollars)

(Whole dollars)

(Whole dollars)

(Whole dollars)

1 - Total medical
assistance accounts
receivable
A - Third Party Liability
B - Probate Court Cases
C - Fraud and Abuse
Cases
D - Provider
Overpayments
E - Audits of annual cost
reports
F - Drug Rebates
G - Other (define)
2 - Less: Allowance for
Uncollectible Amount for
Above Accounts
3 -Total Net Accounts
Receivable
4 - Other Receivables not
in CAFR
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 Medicaid
beneficiary until the State reimburses the provider for the claim.
CMS-R199
OMB No. 0938-0697| Expiration Date: 01/31/2020

|Paperwork Reduction Act