§ 431.972 - Claims sampling procedures.

§ 431.972 Claims sampling procedures.

Cross Reference

Link to an amendment published at 82 FR 31186, July 5, 2017.

(a(a) General requirements. The State will submit quarterly FFS claims and managed care payments, as identified in § 431.970(a), to allow federal contractors to conduct data processing, medical record, and eligibility reviews to meet the requirements of the PERM measurement.

(b) Claims universe.

(1) The PERM claims universe includes payments that were originally paid (paid claims) and for which payment was requested but denied (denied claims) during the

FFY

PERM review period, and for which there is FFP (or would have been if the claim had not been denied) through Title XIX (Medicaid) or Title XXI (CHIP).

(2) The State must establish controls to ensure FFS and managed care universes are accurate and complete, including comparing the FFS and managed care universes to the Form

CMS-64

CMS–64 and Form

CMS-21

CMS–21 as appropriate.

(

b

c) Sample size. CMS estimates

a

each State's annual sample size for

claims

the PERM review at the beginning of the PERM cycle.

(1) Precision and confidence levels. The national annual sample size

should

will be estimated to achieve at least a

State

minimum National-level

error

improper payment rate

within

with a

3

90 percent

precision level at 95 percent

confidence interval

for the claims component of the PERM program, unless the precision requirement is waived by CMS on its own initiative(i) CMS considers the error

of plus or minus 2.5 percent of the total amount of all payments for Medicaid and CHIP.

(2)

Base year sample size. The annual sample size in a State's first PERM cycle (the “base year”) is -

(i) Five hundred fee-for-service claims and 250 managed care payments drawn from the claims universe; or

(ii) If the claims universe of fee-for-service claims or managed care capitation payments from which the annual sample is drawn is less than 10,000, the State may request to reduce its sample size by the finite population correction factor for the relevant PERM cycle.

(3) Subsequent year sample size. In PERM cycles following the base year:

State-specific sample sizes. CMS will develop State-specific sample sizes for each State. CMS may take into consideration the following factors in determining each State's annual state-specific sample size for the current PERM cycle:

(i) State-level precision goals for the current PERM cycle;

(ii) The improper payment rate and precision of that improper payment rate from the State's previous PERM cycle

to determine the State's annual sample size for the current PERM cycle.

(ii) The maximum sample size is 1,000 fee-for-service or managed care payments, respectively.

(iii) If a State measured in the FY 2007 or FY 2008 cycle elects to reject its State-specific CHIP PERM rate determined during those cycles, information from those cycles will not be used to calculate its annual sample size in subsequent PERM cycles and the State's annual sample size in its base year is 500 fee-for-service and 250 managed care payments.

[75 FR 48849, Aug. 11, 2010

;

(iii) The State's overall Medicaid and CHIP expenditures; and

(iv) Other relevant factors as determined by CMS.

[82 FR 31186, July 5, 2017]