Form CMS-21 Quarterly Children’s Health Insurance Program Statement

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2021

Form CMS 21 Summary - Quarterly Children's Health Insurance Program
Statement of Expenditures for Title XXI
Summary Sheet
State:
Quarter Ended: 6/30/2019
Total
Computable Federal Share
Expenditures In This Quarter (Form CMS 21
Base)
1
Adjustments Increasing Claims For Prior
Quarters (Form CMS 21P)
2
Adjustments Decreasing Claims For Prior
Quarters (Form CMS 21P)
3
4
4A
5
6
6A
7

Adjustments Decreasing Claims - Collections
Adjustments Decreasing Claims - MEQC
Collections
Adjustments/Decreasing Claims - Perm (Form
CMS 21Perm)
Adjustments - Decreasing Claims Overpayments
Adjustments - Decreasing Claims -MEQC
Overpayments
Net Expenditures Reported In This Period

Form CMS 21 Summary

Report Date: Monday, June 10, 2019 - 12:00 AM

Department of Health and Human Services
Centers for Medicare & Medicaid Services

OMB No. 0938-1265
Expires 4/30/2021

Form CMS 21OMEQC - Children's Health Expenditures
For the Title XXI Program
Overpayment Adjustments - MEQC
State:
Quarter Ended: 6/30/2019

4

Overpayment Activity
Overpayments Not Collected Or Adjusted But
Refunded Because Of The Expiration Of The 60Day Time Limit
Decreasing Adjustments To Amounts Previously
Reported On Line 1
Subtotal
Previously Reported Overpayments To
Providers Certified This Quarter As Bankrupt Or
Out Of Business

5

Total Overpayment Adjustments This Quarter

1
2
3

Form CMS 21.OMEQC

Total
Computable

2016 And
Prior

2017

2018

Total Federal
2019 Share

Report Date: Monday, June 10, 2019 - 12:00 AM