CMS-10184 Detailed Payment Review Findings

OMB Approval # 0938-1012

Expires: XX/XX/XXXX

Payment Error Rate Measurement (PERM)

Due within 210 days of the end of each sample month.

Detailed Payment Review Findings
State
Date
Program
Sample Month and Year

Case ID	Dropped Due to Beneficiary Fraud	Stratum 1,2 or 3	Review Finding E -eligible EI-eligible with ineligible services NE- not eligible U –undetermined L/O – liability overstated L/U - understated MCE1 – managed care error, ineligible for managed care MCE2 – eligible for managed care but improperly enrolled	Payment Amount Correct	Payment Amount in Error

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.

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