Purpose: These instructions provide guidance on completing the monthly sample selection list. The monthly sample selection list provides the base level information about the cases that have been randomly selected for the given sample month. States submit one monthly Sample Selection List for each month in the sampling timeframe. Both active and negative cases that are sampled in a given month are included on each monthly form. This form is used to submit MEQC data that is substituted for PERM.
This form is due to CMS on the 15th day of the month after the sample month and must be submitted before eligibility reviews begin.
Line by Line Instructions
Line A: State
Enter the name of the State participating in the PERM program that is submitting this report. “State” refers to the 50 States and the District of Columbia. (The Territories are excluded from the PERM program.)
Line B: Date
Enter the date that the Monthly Sample Selection form is being submitted to CMS (e.g. February 15, 2010). If this form is being resubmitted, enter date of resubmission.
Line C: Program
Enter the program for which the Monthly Sample Selection List applies (e.g. Medicaid or CHIP).
Line D: Sample Month
Enter the month for which the sample was drawn from the universe, e.g. January. “Universe” refers to the total number of cases in the sample month. The universe will be unique for each month.
Line E: Number of Cases in the Universe for the Sample Month
Enter the total number of active cases and negative cases in the universe during the sample month. Enter the total number of express lane cases that are excluded from the PERM universe. The active universe is the total number of cases in the sample month that are considered eligible for services based on a completed application, redetermination or are currently on the program rolls. The negative universe is the total number of cases that have either been denied based on a completed application or terminated based on a completed redetermination in the given sample month. The express lane total includes the number of individuals excluded from the PERM universe due to being enrolled in Medicaid or CHIP using express lane eligibility. States substituting MEQC data do not need to stratify cases into the three PERM strata.
Line F: Case/Beneficiary Identification (ID)
“Case” refers to an individual beneficiary, family unit, or assistance unit (AU). In this row, enter the case identification (ID) or beneficiary ID, whichever is the custom of the State that correlates with the case reported as sampled on the monthly sample selection list for the sample month.
For each case selected for the sample of cases, list the case ID in the column in the Active Case column. For each case selected for the sample of negative cases, list the case ID in the Negative Cases column. Express lane eligibility cases are excluded from the PERM universe and must not be sampled.
Add rows if the number of cases in the active case sample for the month being reported exceeds the number of rows provided.
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 (Expires XX/XXXX). The time required to complete this information collection is estimated to average [XXX 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.
A. State |
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B. Date |
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C. Program |
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D. Sample Month |
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E. Number of cases in universe that month |
Active Cases |
Negative Cases |
Express Lane Cases |
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F. Case/Beneficiary Identification |
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| File Type | application/msword |
| Author | JDW-CMS |
| Last Modified By | WILLIAM PARHAM |
| File Modified | 2017-03-31 |
| File Created | 2017-03-31 |