CMS-10184 MEQC substitution Detailed Case Review Findings

INSTRUCTIONS FOR COMPLETING THE PERM ELIGIBILITY REVIEWS:

DETAILED ACTIVE CASE REVIEW FINDINGS

MEQC DATA SUBSTITUTION

Purpose: the detailed active case review findings form provide detailed information about findings from the eligibility reviews of active cases identified on the monthly sample selection list for each sample month. This form is submitted for each month in the sampling timeframe for the sample of active cases.

This form is due within 150 days from the end of the each sample month (i.e. if the sample month is January, the detailed active case review findings form is due on June 30, which is 150 days from January 31).

An “active case” is a case containing information on a beneficiary or family unit enrolled in the Medicaid or CHIP program in the sample month. The active case universe includes all active cases on the rolls from the first day of that month through the last day of the month, with the exception of:

• Negative cases, including all cases that were denied based on completed applications or terminated based on completed redetermination,

• Cases that are under active beneficiary fraud investigation,

• State-only funded cases,

• Supplemental Security Income cases in 1634 States,

• Title IV-E adoption assistance and foster care cases, and

• Cases enrolled in Medicaid or CHIP using express lane eligibility.

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 Detailed Active Case Findings form is being submitted to CMS (e.g. June 15, 2010). If this form is being resubmitted, enter date of resubmission.

Line C: Program

Enter the program for which the monthly Detailed Active Case Findings for applies (e.g. Medicaid or CHIP).

Line D: Sample Month

Enter the month and year for which the sample was drawn from the universe. “Universe” refers to the total number of cases in the sample month. The case universe will be unique for each month.

Line E: 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.

Add rows if the number of cases in the active case sample for the month being reported exceeds the number of rows provided.

• Number of individuals

Enter the number of individuals included in the sampled case.

• Date of Dropped Case

A State can only drop and replace a case from the PERM eligibility sample for the following reasons:

1. A case which should have been excluded from the sampling universe was inadvertently included in the universe and sampled, or

2. A case is found to be under active beneficiary fraud investigation.

“Active beneficiary fraud investigation” is defined as a beneficiary’s name has been referred to the State Fraud and Abuse Control or similar investigation unit and the unit is currently actively pursuing an investigation to determine whether the beneficiary committed fraud.

State should exclude these cases from the universe. However, if a State cannot exclude these cases from the universe, the State can drop these cases if they appear in the sample.

Do not enter a Review Finding for dropped cases.

Other reasons for cases to be dropped from the MEQC review are not applicable for the PERM reviews, e.g. client cannot be located. If a potentially dropped case falls under the classification of an “undetermined” case, it must be reported as such.

• Stratum

Enter the number of the eligibility stratum for the case (e.g. Stratum 1). The strata are as follows:

• Stratum 1—Applications: A case constitutes an “application” for the sample month if the State to an action to grant eligibility in that month based on a completed application.

• Stratum 2—Redeterminations: A case constitutes a “redetermination” for the sample month if the State took an action to continue eligibility in the sample month based on a completed redetermination.

• Stratum 3—All Other Cases: All other cases (properly included in the universe but do not meet the strata one or two criteria) that are on the program in the sample month are placed in stratum three.

• Review Finding

Enter the letter code for the review finding (e.g. MCE1) for each case. The eight review findings are defined as follows:

• E-Eligible: An individual beneficiary meets the State’s categorical and financial criteria for receipt of benefits under the program.

• EI- Eligible with ineligible services: An individual beneficiary meets the State’s categorical and financial criteria for receipt of benefits under the Medicaid or CHIP programs but was not eligible to receive particular services. An example of “eligible with ineligible services” would be a case where the beneficiary did not fully pay his share of cost. Another example would be a person eligible under the medically needy group who received services not provided to the medically needy group.

• NE-Not eligible: An individual beneficiary is receiving benefits under the program but does not meet the State’s categorical and financial criteria for the month eligibility is being verified.

• U-Undetermined: A beneficiary case subject to a Medicaid or CHIP eligibility review decision under PERM about which a definitive determination of eligibility could not be made.

• L/O-Liability overstated: The beneficiary paid too much toward his liability amount or cost of institutional care and the State paid too little. The amount in error is the amount of the State’s underpayment.

• L/U-Liability understated: Beneficiary paid too little toward his liability amount or cost of institutional care and the State paid too much. The amount in error is the amount of the State’s overpayment.

• MCE1-Managed care error, ineligible for managed care: Upon verification of residency and program eligibility, the beneficiary is enrolled in managed care but is not eligible for managed care.

• MCE2-Managed care error, eligible for managed care but improperly enrolled: Beneficiary is eligible for both the program and for managed care but not enrolled in the correct managed care plan as of the month eligibility is being verified.

Leave this column blank if a case is dropped or oversample cases are not used.

• Cause of Error: Enter the cause of the error for cases not eligible for the program. Explanations for this column are not standardized but should reflect the State’s finding that caused the case to be in error. Do not use State-specific codes or abbreviations.

RA 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.

Payment Error Rate Measurement (PERM) Eligibility Reviews:

Detailed Active Case Review Findings

MEQC Data Substitution

Due within 150 days from the end of each sample month

A. State
B. Date
C. Program
D. Sample Month
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