PERM Eligibility Review Tracking Eligibility Form Submission Website https://www.cmspert.org Website Instructions and User Guide Livanta SC Page 2 Created: 10/17/2008 TABLE OF CONTENTS I. OVERVIEW ........................................................................................................................................................ 3 II. REGISTRATION ............................................................................................................................................... 4 III. LOGGING IN ................................................................................................................................................. 5 IV. USING THE ELIGIBILITY REPORTING FORMS ................................................................................. 6 A. FORMS THAT CAN BE SUBMITTED USING PERT ............................................................................................... 6 B. GENERAL INSTRUCTIONS FOR SUBMITTING FORMS ........................................................................................... 7 To Upload the Forms Electronically .................................................................................................................... 7 To Directly Input Data into the PERT Website ..................................................................................................... 8 Saving and Exporting the Forms .......................................................................................................................... 9 Enabling Macros ................................................................................................................................................. 11 C. INSTRUCTIONS FOR SUBMITTING SPECIFIC FORMS .......................................................................................... 11 Monthly Sample Selection List ............................................................................................................................ 12 Detailed Review Findings for Active Case Reviews Form .................................................................................. 13 Detailed Review Findings for Negative Case Review Form ............................................................................... 14 Active Case Payment Findings ........................................................................................................................... 15 Summary Findings and Error Rate Tables ......................................................................................................... 16 Appendix A Eligibility Reporting Forms to be Submitted via PERT Appendix B Instructions for Completing the PERM Eligibility Reviews Appendix C Eligibility Timeline for FY 2009 and Beyond Livanta SC Page 3 Created: 10/17/2008 I. OVERVIEW Starting in FY 2009, each State participating in Payment Error Rate Measurement (PERM) is required to complete reporting forms on both Medicaid and the State Children’s Health Insurance Program (SCHIP) eligibility reviews for each month of the PERM eligibility review process. Copies of the forms are included in Appendix A. Instructions for completing the forms are included in Appendix B. A timeline for FY09 completion of the PERM eligibility review, payment collection and reporting is attached in Appendix C. The PERM Eligibility Review Tracking (PERT) will serve as a vehicle for States to submit their eligibility reporting forms and allows for a central depository for all State-submitted reports. The PERT has two main purposes: 1. Facilitating the accuracy of State reporting by using an electronic process (e.g., reduces potential for user errors in data entry or copying data files, requires data to only be entered once). 2. Providing accurate data for error rate calculation and corrective action analysis. The site will allow data to be easily exported for error rate calculation at the end of the cycle. The site will allow States to either download a form template and upload the completed form back to the site, or fill out the form directly on the website. To upload data, States will input data into the eligibility reporting forms in the Excel template and, following the instructions below, will upload the data to the PERT website. In order to upload data, States will need to save a copy of the file on a local computer and use the same Excel template throughout the review process (i.e., State will use one Excel template for January, one for February, etc.). For States that choose to input the data directly into the form, submitted data will be available for review. States that input data directly on the website will also be able to download copies of submitted data for their own records. If errors are identified in the PERM eligibility universes (e.g., SSI cases are found in the Medicaid universe, State-only funded cases are found in the SCHIP universe, etc.) causing changes to the sample once the monthly sample selection list is sent in, the State cannot change the sample list unless it is due to a statistical matter that would affect the State’s error rate (e.g., errors in the universe). No other changes to samples are allowed. States will need to gain CMS approval before resubmitting a revised sample and should contact Livanta with specific information regarding why the sample is being changed. Once the State has gained the necessary approval, the State will need to resubmit the data using a new eligibility reporting form to the website. Resubmitted data will not delete previously submitted data. The database will keep a record of all submitted data. However, only the latest version will be available for a State to view. States should designate one primary and one secondary staff member to have access to the PERT website. Only two staff members from each State will be able to register for the PERT website and have access to upload or input data. Note on Beneficiary/Claim ID numbers for PERT site: In order to be HIPAA compliant, States that have beneficiary ID numbers that are not randomly assigned (e.g., Social Security numbers) will need to develop dummy beneficiary ID numbers to submit eligibility reporting forms via PERT. States Livanta SC Page 4 Created: 10/17/2008 should develop their own system for developing the dummy beneficiary ID numbers but the numbers should be consistent for each claim throughout the eligibility review process. The dummy ID numbers should be between 6 and 10 characters (e.g., for Pennsylvania Medicaid Stratum One cases: PAMedS101, PAMedS102, etc.) Crosswalks for these dummy claims should be sent in a hard media (e.g., CD) password protected file to CMS when States submit the Monthly Sample Selection List to the PERT website. The crosswalk should be sent to Jessica Woodard, Centers for Medicare & Medicaid Services, C3-02-16, 7500 Security Boulevard, Baltimore, MD 21244-1850. The passwords can be emailed to Jessica Woodard at jessica.woodard@cms.hhs.gov. However, under no circumstances should the crosswalks be emailed directly to CMS due to the inclusion of personal health information. States that already assign random case ID numbers to beneficiaries will not need to develop dummy ID numbers to be able to submit their eligibility reporting forms via the PERT website. II. REGISTRATION The Registration Page (Exhibit 1) will allow States to sign-up for access to the PERT site. To register, click on the ―Click here to register‖ link on the Homepage. This will take you to the page to register as a new user. 1. Select your State from the dropdown box. 2. Enter your First Name, Last Name, and Email Address. 3. Enter a Username of your choice (for example firstname.lastname). Your username is case sensitive. 4. Create a password. Passwords must be at least 8 characters in length, and must contain at least one number, one upper case letter, one lower case letter, and one special character (special characters are !#$%&()*+,-./:;<=>?@[\]^_{|}~). Passwords must be changed every 60 days and States should not use the same password more than once. Passwords are case sensitive. 5. Then, re-enter the password. 6. Click on the Register button. Once you click on the ―Register‖ button, the registration request will be sent to CMS. CMS will process your request by verifying that you are associated with a State participating in the Payment Error Rate Measurement eligibility review for the appropriate fiscal year (State or contractor staff). If your name has not been given to CMS previously, the project director of the State you identified will be contacted to verify that you work on PERM; this may cause the registration process to take a few days. For FY09 States , please make sure that you register at least one month in advance of the first Monthly Sample Selection List submission due date. Livanta SC Page 5 Created: 10/17/2008 Exhibit 1. Registration Page Once the registration is approved, you will receive an email message that will instruct you to click on a link to the website to confirm the registration. This is a protection against someone else registering with your email address. Because the confirmation emails are sent directly from the PERT website, some system firewalls prevent these emails from reaching the intended recipient. If you do not receive a confirmation email within 36 hours, please contact Jessica Woodard at CMS (jessica.woodard@cms.hhs.gov). III. LOGGING IN The Log-in page (Exhibit 2) allows authorized users to sign in to their respective State pages to download eligibility reporting forms, upload eligibility reporting forms, or use the on-line reporting form to enter in data for each sample form. As a reminder, only two authorized users will be permitted to have access to the PERT website and enter reporting information. To enter your State’s site: 1. Go to https://www.cmspert.org. 2. Enter your username and password. Both are case sensitive. 3. Click the log-in button. You will be directed to your State’s page. 4. Be sure to click on the ―Log-out‖ button at the end of each session to ensure the security of your State’s data. Livanta SC Page 6 Created: 10/17/2008 Note: A username is disabled for fifteen minutes after three consecutive failed login attempts. After three consecutive disable cycles, the username is locked out until reset by the administrator. If your username becomes locked out, please email Livanta SC at FY09PERMSC@livanta.com. Three consecutive failed login attempts at the same IP address will lock out that IP address for fifteen minutes. Also, the website will automatically log a user out after being logged on for 60 minutes. Exhibit 2. Log-in Page IV. USING THE ELIGIBILITY REPORTING FORMS A. Forms That Can Be Submitted Using PERT Reporting forms are required for each sample month of the PERM eligibility sampling process to report on the outcomes of sampling, review and payment collection. There are four forms States will submit for each program (Medicaid and SCHIP) to report on each month of the PERM eligibility process and one final summary form (Appendix A). 1. The Monthly Sample Selection List is where States will report the monthly random samples drawn for the active case universe (stratum one, stratum two, and stratum three) and the negative universe. This report is due on the 15th day of the month following each sample month and should be completed before reviews begin. 2. The Detailed Review Findings for Active Case Reviews is where States report on the outcomes of the monthly eligibility reviews for active cases. This form is due 150 days from the end of each sample month. Livanta SC Page 7 Created: 10/17/2008 3. The Detailed Review Findings for Negative Case Reviews form is where States report on the outcomes of the monthly eligibility reviews for negative cases. This form is due 150 days from the end of each sample month. 4. The Detailed Payment Review Findings form is due 210 days from the end of each sample month and is where States report the dollars values associated with the sampled cases. 5. The Summary Findings and Error Rate Tables are due on July 1 following the Federal fiscal year that is being measured. The form includes a summary of findings as well as a reporting of your State program’s error rate. In the future, there will be a mechanism added to the PERT website which will allow States to export the data already submitted into the summary form. States can then use the error rate calculator (currently under development) to calculate the State program’s error rate. Please see Appendix C for an FY09 timeline for submitting the PERM eligibility reporting forms. B. General Instructions for Submitting Forms The PERT website will allow two methods for submitting the Medicaid and SCHIP eligibility reporting forms. The first method is to download the forms electronically in Excel format and enter the data. Then, using a macro, export the file into a CSV format to be uploaded. Livanta will provide an Excel template which will include four worksheets, one for each of the following forms: the Monthly Sample Selection List, the Detailed Review Findings for Active Case Reviews form, the Detailed Review Findings for Negative Case Reviews form, and the Detailed Payment Review Findings form. To successfully upload each form, States will need to run various macros described below, depending on which form is being completed. Each State program (Medicaid and SCHIP) should complete two Excel workbooks per sample month. Once a State downloads a PERM Eligibility Reporting Forms Excel workbook, the State should save the file and use the same Excel workbook throughout the eligibility review process for each sample month (e.g., Medicaid and SCHIP programs should each have a total of twelve Excel workbook files for the FY 2009 PERM Eligibility Review). The second method for submitting the Medicaid and SCHIP Sample Selection Reporting Forms is to input the data directly into the PERT website. Once data has been entered into the reporting form, the data will be uploaded and available in report form for reviewing and printing. Please note that if any forms need to be resubmitted, via either method, States will need to provide a reason for the resubmission (e.g., data entry error, statistical problem with sample). When a State attempts to upload a file for a sample month for which they have already submitted a file, the PERT website will provide a text box and prompt the State to provide a reason for resubmission. Once the state has resubmitted the form, previously submitted forms will no longer be able to be accessed by the State—only the most recent version of the form will be available for States to view. To Upload the Forms Electronically 1. Using the drop-down box, select the specific PERM eligibility reporting form you are uploading and click on the ―Submit‖ button (Exhibit 3). Livanta SC Page 8 Created: 10/17/2008 2. Under Form 1, from the drop-down box ―Select Sample Month,‖ select the sample month of the PERM eligibility reporting form you are submitting to the PERT website. 3. From the drop-down box ―Select Sample Year,‖ choose the appropriate Federal Fiscal Year. 4. From the drop-down box ―Select Program,‖ choose the appropriate program, Medicaid or SCHIP. 5. Then, using the ―Browse‖ button, upload the specified PERM Eligibility Reporting form in CSV format. Note: The file must be saved as a CSV using the macro instructions below. Saving the file as a CSV from Excel will not allow the document to upload correctly. States should run the macro described below to create a CSV file of the report being submitted and then upload the CSV file to the PERT website. Exhibit 3. Uploading PERM Eligibility Forms To Directly Input Data into the PERT Website 1. Using the drop-down box, select the specific PERM eligibility reporting form you are uploading and click on the ―Submit‖ button. 2. Under Form 2, from the drop-down box ―Select Sample Month,‖ select the sample month of the PERM eligibility reporting form you are submitting to the PERT website. 3. From the drop-down box ―Select Sample Year,‖ choose the appropriate Federal Fiscal Year. 4. From the drop-down box ―Select Program,‖ choose the appropriate program, Medicaid or SCHIP. Livanta SC Page 9 Created: 10/17/2008 5. Under Form 2, enter in the data appropriate to the PERM eligibility reporting form you are submitting. For example, to complete the Monthly Sample Selection List (Exhibit 4), enter in the total number of cases in the respective universe and stratum in the first row of fields under each Active Universe Stratum and the Negative Universe. In the remaining fields, under each Active Universe Stratum and the Negative Universe, enter in the Case/Beneficiary ID for each sampled case. Please note that States that have beneficiary ID numbers that are not randomly assigned (e.g., Social Security numbers) will need to develop dummy beneficiary ID numbers to submit eligibility reporting forms via PERT. 6. Once all fields have been populated, click on the ―Submit‖ button. The data will be uploaded to the site. 7. In order to populate repeated fields in the remaining eligibility worksheets, when a State uses the online form to submit Active Case Reviews, Negative Case Reviews, or Payment Review Findings, click on the appropriate links for the Monthly Sample Selection List with the sample date and program of previously completed monthly reports (located under the Form 2 heading). Clicking on one of these links will populate the fields with the beneficiary IDs and strata from the Monthly Sample Selection List. For the Payment Review Findings, clicking the appropriate link for the Active Case Review Findings will populate the fields ―Dropped Due to Beneficiary Fraud‖ and ―Review Findings‖ from the Active Case Review form. Exhibit 4. Direct Input into the PERT website Saving and Exporting the Forms Once the data has been input into each form, States will have to run a macro to populate repeated fields in the other worksheets. See the instructions for each form for the specific combination of keys to press to automatically run the macro. To export and save the data in a file format for uploading, Livanta SC Page 10 Created: 10/17/2008 States will need to populate the form in Excel and save the file as an Excel spreadsheet in the location of your choice (Exhibit 5). As a reminder, the same Excel workbook should be used throughout the eligibility review process for a given sample month. Exhibit 5. Saving the Excel Spreadsheet After saving the file, the State should run the macro for that worksheet (using the instructions in the next section). The Excel form will export the data to a CSV format in the same directory as the Excel file. The CSV file will have the State name, program, sample month, form name, date submitted, and time submitted in its title (Exhibit 6). Note: Only the worksheet that is being populated will export into a CSV format. Exhibit 6. Exporting the Excel spreadsheet into CSV format Livanta SC Page 11 Created: 10/17/2008 Enabling Macros The Excel workbook requires States to run a macro to convert the data into a format for uploading. Many States’ IT networks will not automatically allow macros to run. States may need to adjust their computer security settings and ―enable macros‖ in order for the spreadsheet to work correctly. Before exporting the forms to CSV, proceed with the following steps: 1. Open Excel. 2. Click on ―Tools‖ and then ―Options.‖ 3. In the ―Options‖ box, click on the ―Security‖ tab. 4. Under the ―Security‖ tab, click on the ―Macro Security‖ button. 5. Change your macro security to ―Medium.‖ This will allow Excel to offer you the choice to enable the macro. The macros need to run only in the PERM eligibility reporting form document. 6. Open the PERT Excel file and click on the ―Enable Macro‖ button (Exhibit 7). Exhibit 7. Enabling Macros C. Instructions for Submitting Specific Forms As noted above, four forms can be submitted using the PERT: the Monthly Sample Selection List, Detailed Review Findings for Active Case Reviews Report, Detailed Review Findings for Negative Case Reviews Report, and Detailed Payment Review Findings Report. Livanta SC Page 12 Created: 10/17/2008 Exhibit 8. Selecting form for submission Monthly Sample Selection List To download and submit the Monthly Sample Selection List electronically: 1. After logging in, select the ―Submit reports‖ link. 2. Using the drop down menu, States should select the form they will be submitting in order to proceed (Monthly Sample Selection List). (Exhibit 8) 3. Click the ―Submit‖ button. 4. Click on the link at the top of the page to download the monthly report CSV form: ―Click here to download the PERM Eligibility Tracking Tool spreadsheet forms.‖ 5. When the Excel spreadsheet opens, click on the ―Enable macros‖ button (Exhibit 4). The workbook containing the four forms will then open in Excel. 6. Save the file – you may want to rename with the State name and month (e.g., ―NH SCHIP March 08 PERM Eligibility Reporting Forms‖). You will use the same file to populate the remaining three forms for this month. 7. Click on the tab for the Monthly Sample Selection List form. 8. Enter data into the form only in the outlined fields. If copying the data into the spreadsheet, please be sure that numbers are imported as numbers rather than text and that text is imported as text and not numbers. Also, please do not change any column Livanta SC Page 13 Created: 10/17/2008 headings or text. Failure to comply with these guidelines will prevent successful uploading of the reporting forms. If states are creating dummy case ID numbers, they must send a crosswalk to the CMS. Columns are provided on the Monthly Sample Selection List template for states to input the crosswalk information (i.e., the actual beneficiary/case ID number that corresponds to the dummy value in the Case/Beneficiary ID field). The crosswalk columns will not be uploaded to the PERT (when the macro is run to create a CSV, in Step 11, the crosswalk will not populate in the CSV). However, States can send a copy of the file to CMS to meet the crosswalk notification requirement. Also, please note that additional rows are provided in the Monthly Sample Selection List template for states to submit those cases selected as the oversample, if they choose to submit these cases with the rest of the sample. 9. Once the data has been input into the form, States will be able to run a macro to populate repeated fields in the other worksheets. Press the ―Control-Shift-G‖ keys simultaneously and the fields ―Case/Beneficiary ID‖ will automatically populate in the remaining forms and the ―Strata‖ field will populate in the Active Case Review Findings form as well as the Active Case Payment Findings form. 10. Once the data has been input into the form, the spreadsheet will need to be saved as a CSV file. First, save the file as an Excel spreadsheet in the location of your choice. 11. After saving the file, click on the tab for the Monthly Sample Selection List and press the ―Control-Shift-L‖ keys simultaneously on your keyboard. After running the macro, the Excel form will export the data to a CSV format in the same directory as the Excel file. The CSV file will have the State name, program, sample month, form name, date submitted, and time submitted in its title. Upload the exported CSV file to the PERT website. Note: Only the worksheet that is being populated will export into a CSV format. Detailed Review Findings for Active Case Reviews Form To complete and submit the Detailed Review Findings for Active Case Reviews form: 1. After logging, in select the ―Submit reports‖ link. 2. Using the drop down menu, States should select the form they will be submitting in order to proceed (Detailed Review Findings for Active Case Reviews form). (Exhibit 8) 3. Click the ―Submit‖ button. 4. Open the Excel workbook for the relevant month from your computer. 5. When the Excel spreadsheet opens, click on the ―Enable macros‖ button. The workbook containing the four forms will then open in Excel. 6. Click on the tab for the Active Case Review Findings form. Livanta SC Page 14 Created: 10/17/2008 7. Enter data into the form only in the outlined fields. If copying the data into the spreadsheet, please be sure that numbers are imported as numbers rather than text and that text is imported as text and not numbers. Also, please do not change any column headings or text. Failure to comply with these guidelines will prevent successful uploading of the reporting forms. 8. Once the data has been input into the form, the fields ―Dropped Due to Beneficiary Fraud‖ and ―Review Finding‖ will automatically populate in the Active Case Payment Findings form. 9. Once the data has been input into the form, the Active Case Review Findings form will need to have the page breaks removed. This can be done by pressing the ―Control-Shift-H‖ keys simultaneously. 10. Once the data has been input into the form and the line breaks have been removed, the spreadsheet will need to be saved as a CSV file. First, save the file as an Excel spreadsheet in the location of your choice. As a reminder, the same Excel workbook should be used throughout the eligibility review process for a given sample month and program. 11. After saving the document, click on the tab for the Detailed Review Findings for Active Case Review form and press the ―Control-Shift-L‖ keys simultaneously on your keyboard. After running the macro, the Excel form will export the data to a CSV format in the same directory as the Excel file. The CSV file will have the State name, report name, sample month, date submitted and time submitted in its title. Upload the exported CSV file to the PERT website. Note: Only the worksheet that is being populated will export into a CSV format. Detailed Review Findings for Negative Case Review Form To complete and submit the Detailed Review Findings for Negative Case Review form: 1. After logging, in select the ―Submit reports― link. 2. Using the drop down menu, States should select the form they will be submitting in order to proceed (Detailed Review Findings for Negative Case Reviews form). (Exhibit 8) 3. Click the ―Submit‖ button. 4. Open the Excel workbook for the relevant month from your computer. 5. When the Excel spreadsheet opens, click on the ―Enable macros‖ button. The workbook containing the four forms will then open in Excel. 6. Click on the tab for the Negative Case Review Findings form. 7. Enter data into the form. If copying the data into the spreadsheet, please be sure that numbers are imported as numbers rather than text and that text is imported as text and not numbers. Also, please do not change any column headings or text. Failure to comply with these guidelines will prevent successful uploading of the reporting forms. Livanta SC Page 15 Created: 10/17/2008 8. Once the data has been input into the form, the Negative Case Review Findings form will need to have the page breaks removed. This can be done by pressing the ―Control-Shift-J‖ keys simultaneously. 9. Once the data has been input into the form and the line breaks have been removed, the spreadsheet will need to be saved as a CSV file. First, save the file as an Excel spreadsheet in the location of your choice. As a reminder, the same Excel workbook should be used throughout the eligibility review process for a given sample month and program. 10. After saving the document, click on the tab for the Detailed Review Findings for Negative Case Reviews and press the ―Control-Shift-L‖ keys simultaneously on your keyboard. After running the macro, the Excel form will export the data to a CSV format in the same directory as the Excel file. The CSV file will have the State name, report name, sample month, date submitted and time submitted in its title. Upload the exported CSV file to the PERT website. Note: Only the worksheet that is being populated will export into a CSV format. Active Case Payment Findings To complete and submit the Active Case Payment Findings form: 1. After logging, in select the ―Submit reports―link. 2. Using the drop down menu, States should select the form they will be submitting in order to proceed (Active Case Payment Findings). (Exhibit 8) 3. Click the ―Submit‖ button. 4. Open the Excel workbook for the relevant month from your computer. 5. When the Excel spreadsheet opens, click on the ―Enable macros‖ button. The workbook containing the four forms will then open in Excel. 6. Click on the tab for the Active Case Payment Findings form. 7. Enter data into the form. If copying the data into the spreadsheet, please be sure that numbers are imported as numbers rather than text and that text is imported as text and not numbers. Also, please do not change any column headings or text. Failure to comply with these guidelines will prevent successful uploading of the reporting forms. 8. Once the data has been input into the form, the Active Case Payment Findings form will need to have the page breaks removed. This can be done by pressing the ―Control- Shift- K‖ keys simultaneously. 9. Once the data has been input into the form and the line breaks have been removed, the spreadsheet will need to be saved as a CSV file. First, save the file as an Excel spreadsheet in the location of your choice. As a reminder, the same Excel workbook should be used throughout the eligibility review process for a given sample month and program. Livanta SC Page 16 Created: 10/17/2008 10. After saving the document, press the ―Control-Shift-L‖ keys simultaneously on your keyboard. After running the macro, the Excel form will export the data to a CSV format in the same directory as the Excel file. The CSV file will have the State name, sample month, and date submitted in its title. Upload the exported CSV file to the PERT website. Note: Only the worksheet that is being populated will export into a CSV format. Summary Findings and Error Rate Tables The Summary Findings and Error Rate Tables will include a summary of findings as well as a reporting of your State program’s error rate. In the future, there will be a mechanism added to the PERT website which will allow States to export the data already submitted into the summary form. States can then use the error rate calculator, which is currently under development, to calculate the State program’s error rate. Livanta SC will contact States when these features are available for use. Livanta SC Page 17 Created: 10/17/2008 APPENDIX A Eligibility Reporting Forms to be Submitted via PERT Monthly Sample Selection List OMB No. 0938-1012 Payment Error Rate Measurement (PERM) Eligibility Reviews: Cases Selected for Review: Monthly Sample Selection List Due on the 15th day of the month after the sample month and before the eligibility reviews begin. Monthly Sample Selection List A. State B. Date C. Program D. Sample Month & Year E. Number of cases in universe that month Stratum 1 Applications Stratum 2 Redeterminations Stratum 3 All Other Cases Negative Cases F. Case/Beneficiary Identification Case/ Beneficiary Identification Case/ Beneficiary Identification Case/ Beneficiary Identification 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) Livanta SC Page 18 Created: 10/17/2008 11) 12) 13) 14) 15) 16) 17) 18) 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 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 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. Form CMS-10184A Livanta SC Page 19 Created: 10/17/2008 Detailed Review Findings for Active Case Reviews OMB No. 0938-1012 Payment Error Rate Measurement (PERM) Eligibility Reviews: Detailed Review Findings for Active Case Reviews Due within 150 days from the end of each sample month. E. Case ID Review Month 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 Cause of Error, if known Example: excess income, non-resident. 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) A. State B. Date C. Program D. Sample Month & Year Livanta SC Page 20 Created: 10/17/2008 12) 13) 14) 15) 16) 17) 18) 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 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 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. Form CMS-10184B Livanta SC Page 21 Created: 10/17/2008 Detailed Findings for Negative Cases OMB No.0938-1012 Payment Error Rate Measurement (PERM) Eligibility Reviews: Detailed Findings for Negative Cases Due within 150 days of the end of each sample month. E. Case/ Beneficiary ID Denial or Termination D – denial T - termination Review Finding C – correct ID – improper denial IT – improper termination Cause of Error, if known 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) A. State B. Date C. Program D. Sample Month and Year Livanta SC Page 22 Created: 10/17/2008 15) 16) 17) 18) 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 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 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. Form CMS-10184C Livanta SC Page 23 Created: 10/17/2008 Detailed Payment Review Findings OMB No. 0938-1012 Payment Error Rate Measurement (PERM) Eligibility Reviews: Detailed Payment Review Findings Due within 210 days of the end of each sample month. Payment Error Rate Measurement (PERM) Eligibility Reviews: Detailed Payment Review Findings Due within 210 days of the end of each sample month. A. State B. Date C. Program D. Sample Month & Year E. Case ID Dropped Due to Beneficiar y Fraud Stratu m 1,2 or 3 Review Finding Paymen t Amount Correct Payment Amount in Error Amount Undetermine d 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 Livanta SC Page 24 Created: 10/17/2008 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 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 Livanta SC Page 25 Created: 10/17/2008 control number for this information collection is 0938-1012. The time required to complete this information collection is 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 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. Form CMS-1018 Livanta SC Page 26 Created: 10/17/2008 APPENDIX B Instructions for Completing the PERM Eligibility Reviews: Cases Selected for Review: Monthly Sample Selection List 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 Report 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 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, 2007). Line C: Program Enter the program for which the Monthly Sample Selection List applies (e.g., Medicaid or SCHIP). Line D: Sample Month and Year Enter the month and year for which the sample was drawn from the universe, e.g., January 2007. ―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 (per stratum) and negative cases in the universe during the sample month. 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 (see below). 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. For active cases, include the number of cases in each stratum in the respective column as follows: 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. 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. 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. Livanta SC Page 27 Created: 10/17/2008 Negative Cases - A negative case contains information on a beneficiary who 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. Line F: Case/ Beneficiary ID ―Case‖ refers to an individual beneficiary and, for PERM purposes, is not a household or family unit. 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 active cases, list the case ID in the column for the respective stratum (e.g., Stratum 1, Stratum 2, Stratum 3). For each case selected for the sample of negative cases, list the case ID in the Negative Cases column. Line G: Crosswalk (use if needed) Columns are provided for states to input the crosswalk information or the actual beneficiary/case ID number that corresponds to the dummy value in the Case/Beneficiary ID field. The crosswalk columns will not be uploaded to the PERT . When the macro is run to create a CSV, the crosswalk will not populate in the CSV. However, States can send a copy of the file to CMS to meet the crosswalk notification requirement. Livanta SC Page 28 Created: 10/17/2008 Instructions for Completing the PERM Eligibility Reviews: Detailed Review Findings for Active Case Reviews Purpose: The detailed active case review findings form provides 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 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 who was enrolled in the Medicaid or SCHIP 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 redeterminations, Cases that are under active beneficiary fraud investigation, Supplemental Security Income cases in 1634 States, Title IV-E adoption assistance and foster care cases, and Cases which are paid with state funds. 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, 2009). Line C: Program Enter the program for which the monthly Detailed Active Case form applies (e.g., Medicaid or SCHIP). Line D: Sample Month and Year 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 ID ―Case‖ refers to an individual beneficiary and, for PERM purposes, is not a household or family unit. In this row, enter the case identification (ID) or beneficiary ID, whichever is the custom of the State, which correlates with the case reported as sampled on the monthly sample selection list for the same sample month. Review Month Enter the review month for which eligibility was verified (the review month is not necessarily the same as the sample month). Generally, the review month is the same as the sample month for cases in strata 1 and 2 because, for PERM purposes, the review Livanta SC Page 29 Created: 10/17/2008 month is when the State’s last action occurred. However, in strata 3, the timeframe for verifying eligibility could differ. Generally, eligibility also would be verified as of the month of the State’s last action; but if that action occurred more than 12 months prior to the sample month, then eligibility is reviewed as of the sample month. In the ―Review Month‖ column, enter the month in which eligibility was verified, i.e., either the review month or the sample month, as appropriate to each case. Dropped Due to Beneficiary Fraud ―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. States should exclude cases under active beneficiary fraud investigation 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. If a case was dropped from the sample due to an active beneficiary fraud investigation, note the date the case was dropped (e.g., 6/15/09). If the case was not dropped, leave this column blank. 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 sampling month if the State took an action to grant eligibility in that month based on a completed application. States should count an individual reapplying for Medicaid or SCHIP after a break in eligibility as a new application and place the case in stratum one.  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.  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 SCHIP 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. Livanta SC Page 30 Created: 10/17/2008  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 SCHIP eligibility determination 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.  L/U - Liability understated – Beneficiary paid too little toward his liability amount or cost of institutional care and the State paid too much.  MCE1 - Managed care error, ineligible for managed care – Upon verification of residency and program eligibility, and 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. Cause of Error, if known - Enter the cause of the error, if known, 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. Livanta SC Page 31 Created: 10/17/2008 Instructions for Completing the PERM Eligibility Reviews: Detailed Findings for Negative Case Reviews Purpose: These instructions provide guidance on completing the Detailed Negative Case Review form. This form provides detailed information about findings from the review of negative cases in the monthly sample. This report is due within 150 days from the end of the sample month (i.e., if the sample month is January, the form is due on June 30, which is 150 days from January 31). A “negative case” is a case containing information on a beneficiary who completed an application for benefits and was denied or who completed the redetermination process but whose program benefits were terminated based on the State agency’s eligibility decision. The negative case universe includes all cases that were denials of eligibility based on completed applications in a given month and all active cases that were found to be ineligible based on completed redeterminations and moved from active to negative in the month. 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 Negative Case Findings form is being submitted to CMS (e.g., June 15, 2009). Line C: Program Enter the program for which the monthly Detailed Negative Case form applies (e.g., Medicaid or SCHIP). Line D: Sample Month and Year 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 ID ―Case‖ refers to an individual beneficiary and, for PERM purposes, is not a household or family unit. In this row, enter the case 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. Denial or Termination Denial – Means an application was completed by the beneficiary but was rejected for not meeting eligibility requirements. Termination – Means an existing beneficiary completed the redetermination process but no longer meets eligibility requirements and is therefore not eligible for the program. Enter ―D‖ if the case was a denial. Enter ―T‖ if the case was a termination. Livanta SC Page 32 Created: 10/17/2008 Line E - continued Review Finding Enter the letter code for the review finding. The three review findings are defined as follows:  C - Correct – The negative case was properly denied or terminated by the State.  ID - Improper denial – The application for program benefits was denied by the State for not meeting the categorical and/or financial eligibility requirements but upon review is found to be eligible.  IT - Improper termination – Based on a completed redetermination, the State determines an existing beneficiary no longer meets the program’s categorical and/or financial eligibility requirements and is terminated but upon review is found to still be eligible. Cause of Error, if known Enter the cause of the error, if known. Explanations for this column are not standardized but should reflect the State’s eligibility determination policies. Do not use State-specific codes or abbreviations. Livanta SC Page 33 Created: 10/17/2008 Instructions for Completing the PERM Eligibility Reviews: Detailed Findings for Payment Review Purpose: The Detailed Payment Review Findings form provides detailed payment review findings for all cases in each monthly sample. This form identifies the total dollars paid, the amount correctly paid and the amount paid in error for each case, as appropriate, in the sample for a given month. This form is due 210 days from the end of the sample month (i.e., the payment review for the sample month of January is due on August 31, which is 210 days from January 31). 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 Payment Review form is being submitted to CMS (e.g., June 15, 2009). Line C: Program Enter the program for which the monthly Detailed Payment form applies (e.g., Medicaid or SCHIP). Line D: Sample Month and Year 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 ID ―Case‖ refers to an individual beneficiary and, for PERM purposes, is not a household or family unit. In this row, enter the case ID or beneficiary ID, whichever is the custom of the State, which correlates with the case reported as sampled on the monthly sample selection list for the sample month. Note: Include all sampled cases in this table, not just those with payment errors. Dropped Due to Beneficiary Fraud ―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. States should exclude cases under active beneficiary fraud investigation 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. If a case was dropped from the sample due to an active beneficiary fraud investigation, note the date the case was dropped (e.g., 6/15/09). If the case was not dropped, leave this column blank. Livanta SC Page 34 Created: 10/17/2008 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 sampling month if the State took an action to grant eligibility in that month based on a completed application.  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.  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). 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 SCHIP programs but was not eligible to receive particular services. An example would be a person eligible under 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 SCHIP eligibility determination 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.  L/U - Liability understated – Beneficiary paid too little toward his liability amount or cost of institutional care and the State paid too much.  MCE1 - Managed Care error, ineligible for Managed Care – Upon verification of residency and program eligibility, and 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. Livanta SC Page 35 Created: 10/17/2008 Payment Amount Correct – A correct payment amount is a payment to a provider, insurer, or Managed Care Organization based on the beneficiary’s eligibility for the program and for the services received under the coverage group under which the beneficiary is eligible as defined in the State’s plan. For FFS cases, enter the total amount of dollars paid for the beneficiary based on claims for services rendered at any time in the spend down period (if appropriate) through the review month or are rendered in the sample month (for cases in stratum 3) which are paid by the end of the fourth month after the review month (or sample month for cases in stratum 3). For Managed Care cases, enter the capitated amount paid for the case. All managed care payments made for coverage in the review month (for strata 1 and 2 cases) and the sample month (for stratum 3 cases) are included regardless of the actual payment date so long as the payment dates fall within the review month (for cases in strata 1 and 2) or sample month and are paid by the end of the fourth month after the review month or sample month. Enter the portion of the payments, in part or in whole as appropriate, that were correct for each sampled case. Payment Amount in Error – Enter the amount of payment that is in error based on the beneficiary’s: - ineligibility for services received. - ineligibility for the program, - liability overstated or understated, - ineligibility for Managed Care, - eligibility for Managed Care but enrollment in the wrong Managed Care plan. Enter the portion of the payment, in whole or in part, that was in error for each sampled case. Livanta SC Page 36 Created: 10/17/2008 Instructions for Completing the PERM Eligibility Reviews: Summary Review Findings and Error Rate Purpose: The Summary Case Review and Error Rate Form 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 2009, the summary report is due by July 1, 2010). 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, 2010). 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. States should count an individual reapplying for Medicaid or SCHIP after a break in eligibility as a new application and place the case in stratum one. 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. 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 Livanta SC Page 37 Created: 10/17/2008 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 the 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 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 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 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 Cases Eligible Column Enter the number of cases deemed to be eligible through the PERM Livanta SC Page 38 Created: 10/17/2008 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 Ineligible 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. Livanta SC Page 39 Created: 10/17/2008 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 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%). Livanta SC Page 40 Created: 10/17/2008 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. Livanta SC Page 41 Created: 10/17/2008 Appendix C Eligibility Timeline for FY 2009 and Beyond