CMS-10184.revised summary and error rate tables (clean copy)

INSTRUCTIONS FOR COMPLETING THE PERM ELIGIBILITY REVIEWS:

SUMMARY FINDINGS AND ERROR RATE TABLES

Purpose: The Summary Findings and Error Rate Tables provides summary case review findings from the review of all cases

in the monthly active and negative case samples as well as the payment and case error rates, as appropriate. This form

provides comprehensive data for active cases (total and for each of the three stratum) and negative cases (total, denials and

terminations).

This form is due by July 1st following the fiscal year being measured (i.e., for States completing PERM eligibility reviews for

fiscal year 2007, the summary report is due by July 1, 2008).

Line by Line Instructions

SUMMARY FINDINGS TABLE:

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 Summary Case Review and Error Rate form is being submitted to CMS (e.g., Jul y 1, 2008).

Line C: Program

Enter the program for which the Summary Case Review and Error Rate form applies (e.g., Medicaid or SCHIP).

Line D: Active

Enter the total number of active cases equal to the sum of Strata 1, 2 and 3. An active case is a case containing information on a

beneficiary who was enrolled in the program in the sample month.

Stratum 1–Applications: A case constitutes an “application” for the sampling month if the State took an action to grant

eligibility in that month based on a completed application.

Enter the total active cases in Stratum 1, Applications, sampled for the fiscal year.

Stratum 2–Redeterminations: A case constitutes a “redetermination” for the sampling month if the State took an action

to continue eligibility in the sample month based on a completed redetermination.

Enter the total active cases in Stratum 2, Redeterminations, sampled for the fiscal year.

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.

Enter the total active cases in Stratum 3, All other cases, sampled for the fiscal year.

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FORM CMS-10184E (01/07) EF (02/2007)

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved

OMB No. 0938-1012

FORM CMS-10184E (01/07) EF (02/2007)

Line E: Negative

A negative case is a case where a beneficiary completed an application for benefits and the State denied the application or who

completed the redetermination process but whose program benefits were terminated by the State.

Enter the total number of negative cases; equal to the sum of Denials and Terminations.

Denials—Denials occur when the State rejected a completed application for not meeting categorical and financial

eligibility requirements.

Enter the total number of denials sampled for the fiscal year.

Terminations—Terminations occur when an existing beneficiary no longer meets eligibility requirements and the State

took an action to terminate program eligibility.

Enter the total number of terminations sampled for the fiscal year.

Line F: Total

Enter the total number of cases in each column. For example, in column one, enter the total number of cases in the universe. In

column two, enter the total number of cases sampled in each stratum of the active cases and total number of cases sampled as

denied and terminated for negative cases. In column three, enter the total number of cases excluded due to beneficiary fraud.

For each row, enter the appropriate numbers in each column, as follows:

Number of Total Cases in the Universe Column

Enter the number of cases in the universe subject to sampling for the months reviewed throughout the fiscal year.

Number of Total Cases Sampled Column

Enter the number of cases sampled in each of the categories described in the rows. These should equal the totals

reported on the Monthly Sample Selection Lists.

Number of Total Cases Excluded due to Beneficiary Fraud Column

Enter the number of cases excluded from the sample due to beneficiary fraud in each of the categories described in the

rows. These should equal the number of beneficiary fraud cases reported on the monthly Detailed Active Case Review

Findings form.

The cells should be left blank in the Negative, Denials, and Terminations rows.

Number of Total Cases Correct Column

Enter the number of cases deemed to be eligible through the PERM eligibility reviews in each of the categories

described in the rows.

These should equal the number of cases reported on the Detailed Active Case Review Findings forms completed

throughout the fiscal year with findings of “E—eligible,” “EI—eligible for ineligible services,” “L/O—liability overstated,”

“L/U—liability understated,” “MCE1—managed care error, ineligible for managed care,” or “MCE2 — eligible for

managed care but improperly enrolled.”

Enter the number of denied and terminated cases found eligible through the negative case action reviews throughout

the fiscal year as reported on the Detailed Negative Case Review Findings forms (codes ID for incorrect denials and IT

for incorrect terminations) .

Number of Cases Incorrect Column

Enter the number of cases deemed to be ineligible through the PERM eligibility review in each of the categories

described in the rows.

These should equal the number of cases reported on the Detailed Active Case Review Findings forms completed

throughout the fiscal year with a findings of “NE—not eligible.”

Enter the number of denied and terminated cases found ineligible through the negative case action reviews throughout

the fiscal year as reported on the Detailed Negative Case Review Findings forms (code C for cases that were correctly

denied and terminated).

Number of Cases Undetermined Column

Enter the number of cases for which the State was unable to determine eligibility in each of the categories described in

the rows.

These should equal the number of cases reported on the Detailed Active Case Review Findings forms completed

throughout the fiscal year with findings of “U--undetermined.”

The cells should be left blank in the Negative, Denials, and Terminations rows because, if no evidence exists to support

a denial or termination, the case is cited as an improper denial or termination.

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FORM CMS-10184E (01/07) EF (02/2007)

TOTAL DOLLARS PAID COLUMN Enter the total dollars paid that corresponds with each of the categories described in the rows.

The cells should be left blank in the Negative, Denials, and Terminations rows because payment reviews are not

completed for negative case reviews.

TOTAL DOLLARS CORRECT COLUMN

Enter the total dollars paid correctly that corresponds with each of the categories described in the rows.

The cells should be left blank in the Negative, Denials, and Terminations rows because payment reviews are not

completed for negative case reviews.

TOTAL DOLLARS IN ERROR COLUMN

Enter the total dollars found in error that corresponds each of the categories described in the rows.

The cells should be left blank in the Negative, Denials, and Terminations rows because payment reviews are not

completed for negative case reviews.

ERROR RATE TABLE:

Line G: Active Payment Error Rate

Enter the amount of projected improper payments represented in the universe in the Dollar Amount in Error column.

The active payment error rate is a “dollar weighted” error rate. The dollar value of claims for services provided in the

month of eligibility review are used to calculate the payment error rate. Enter the payment error rate as calculated for

your State in the Error Rate column. Please report the error point with one decimal, e.g., 94.2%.

Enter the confidence and precision of the computed error rate—which should be 95.0%, +/- 3 %—in the Confidence and

Precision column.

The Percentage column is not applicable and should be left blank.

Line H: Active Case Error Rate

The Active Case error rate is a simple case error rate; therefore, the Dollar Amount column is not applicable and should

be left blank.

Enter the case error rate as calculated for your State in the Error Rate column. Please report the error point with one

decimal (e.g., 94.2%).

Enter the confidence and precision of the case error rate—which should be 95.0%, +/- 3 % - in the Confidence and

Precision column.

The Percentage column is not applicable and should be left blank.

Line I: Negative Case Error Rate

The negative case error rate is a simple case error rate (valid or invalid eligibility) for negative cases. Enter the case error

rate as calculated for your State in the Error Rate column. Please report the error point with one decimal (e.g., 94.2%).

Enter the confidence and precision of the computed case error rate—which should be 95.0%, +/- 3 % - in the Confidence

and Precision column.

The Percentage column is not applicable and should be left blank.

Line J: Undetermined Cases

Enter the dollar amount represented in the universe in the Dollar Amount column.

The Error Rate and Confidence and Precision columns should be left blank.

Enter the percentage of the sample represented by undetermined cases in the Percentage Column.

Payment Error Rate Measurement (PERM) Eligibility Reviews:

Summary Findings and Error Rate Tables

Due July 1 following the Federal fiscal year being measured.

A. State
B. Date
C. Program
	Number of Cases in Universe	Number of Cases Sampled	Number of Fraud Cases Excluded from the Universe or Sample	Number of Cases Correct	Number of Cases Incorrect	Number of Cases Undetermined	Total Dollars Paid	Total Dollars Correct	Total Dollars in Error
D. Active
Stratum 1
Stratum 2
Stratum 3
E. Negative
Denials
Terminations
F. Totals

Error Rate Table

	Dollar Amount in Error	Error Rate	Confidence And Precision	Percentage
G. Active Payment Error Rate				N/A
H. Active Case Error Rate	N/A			N/A
I. Negative Case Error Rate	N/A			N/A
J. Undetermined Cases		N/A	N/A

I certify that this information is accurate and that the State will maintain the sampled case records used in the calculation of this reported error rate for a minimum period of three years. I understand that this information may be subject to Federal review and that our sampled case records and calculations are subject to Federal audit.

Signature: _______________________________________ Date: _______________

State Medicaid/SCHIP Director or Designee

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 is 0938-1012. The time required to complete this information collection estimated to average 100 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 any comments concerning the accuracy of the

time estimate(s) or suggestions for improving this form, please write to: CMS, Attention: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.