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PERM Frequently Asked Questions (FAQs) General
Claims
Eligibility
General
1. What is PERM? The Payment Error Rate Measurement or PERM is a comprehensive federal review of how frequently errors occur when Medicaid claims are processed. It will include paid claims and denied claims. The PERM will be used to calculate a payment error rate.
2. Is Oregon the only state that has been chosen? No, all 50 states will be measured; 17 each year. Oregon will participate in fiscal 2008 and will continue to be measured once every three years.
3. Why is this federal review happening? The Centers for Medicare and Medicaid Services (CMS) is required to conduct PERM under the Improper Payment Information Act of 2002 (IPIA; Public Law 107-300). The IPIA directs agencies to review programs at risk for payment errors and to report improper payments.
4. When will Oregon’s review start? Starting in January 2008, Oregon’s Medicaid program must begin sending Medicaid claims data and copies of all related state policies to a federal contractor. The claims data will reflect claims submitted to Oregon Medicaid during the last quarter of 2007 (Oct. 1 through Dec. 31, 2007).
5. Who is going to conduct the PERM review? The Centers for Medicare and Medicaid Services (CMS) has contracted with three national contractors to conduct the review. They include:
6. When will a payment error rate for Oregon be determined? Oregon’s payment error rate will be determined when the review of all claims has been completed.
7. Where can I get more information on PERM? You can find more information on the Centers for Medicare and Medicaid Services (CMS) Web site:
8. What if I have more questions? Please e-mail your questions about PERM to opar.oregonperm@state.or.us
Claims
9. How many claims will be reviewed during the PERM review? Approximately 1,200 Oregon Medicaid claims will be reviewed. About 300 claims will be reviewed each quarter beginning with claims randomly selected from those submitted Oct. 1 through Dec. 31, 2007.
10. Does this review include fee-for-service claims and managed care claims? The review will definitely include fee-for-service claims. CMS has indicated that managed care claims also will be included; however, Oregon has not yet received instructions from CMS regarding that process.
11. I’ve sent claims to Oregon Medicaid. How does this affect me? If you submitted a claim to Oregon and it is randomly selected for review, you will receive a letter from the CMS data documentation contractor asking you to send copies of medical records and other documentation that supports the submitted claim. The data documentation contractor will tell providers what to send, where to send it and when.
The documentation may include medical information, proof of medical necessity, and proof that the services were provided as ordered and billed and that the claim has the correct CPT/HCPCS and ICD-9-CM codes. It is crucial that you respond. Documentation that is incomplete or inaccurate may be counted as an error. Failure to send the requested documentation will be counted as an error.
12. Will I be notified if an error is discovered with one of my paid claims? Yes. You will be notified by letter.
13. What if an error is confirmed? States are required to return to CMS the federal share of any overpayment. If an error is confirmed we anticipate an adjustment will be made; however we are still waiting for instructions from CMS. This Web site will be updated as we receive more information.
14. One of my claims was determined to have an error and I want to appeal the decision. What do I need to do? There will be an appeal process. Exactly how the appeal process will work is still being developed. This Web site will be updated as we receive more information.
15. How will patient privacy be maintained? The Health Insurance Portability and Accountability Act (HIPAA) allows for the collection and review of protected health information for the CMS PERM review. Providers are required by Section 1902(a)(27) of the Social Security Act to disclose information for state and federal reviews. Special permission from patients is not required for the release of records for PERM reviews. Records do not need to be "de-identified" before they are sent to the data documentation contractor.
16. How long do I have to keep client medical records? The State of Oregon requires you to retain clinical records for seven years and financial and other records for at least five years from date of service (OAR 410-120-1306 (2)).
Eligibility 17. I am a caseworker, how does PERM apply to me? The Payment Error Rate Measurement, or PERM, is a comprehensive federal review. There are two components to PERM, the provider claims reviews and the eligibility reviews. The eligibility review will measure how frequently errors may occur when processing Medicaid claims. PERM requires a review of eligibility decisions and managed care enrollment. When Oregon’s PERM review is completed a payment error rate will be determined.
18. When will Oregon’s eligibility review start? Eligibility reviews began in November for the October – September 2008 federal fiscal year. The first eligibility findings are due to CMS in March. Initial feedback will be given to the branches beginning in February.
19. Who is going to conduct the PERM eligibility reviews? Eligibility reviews are being conducted by analysts in the Quality Control Unit of the Department of Human Services.
20. How many cases will be reviewed during the PERM review? Each month, Quality Control reviews 84 Medicaid and SCHIP active cases and 34 negative cases for correct eligibility and managed care plan enrollment. Active cases are actions to approve benefits and can be in one of three categories: new, redeterminations or ongoing cases. Negative cases are actions to terminate or deny benefits within the sample month.
21. Will I be notified if an error is discovered with one of my cases? Yes. Quality Control will send an error report to field offices. QC may also communicate case findings not resulting in a payment error as a technical error report, information only report, by E-mail or by phone.
Quality Control invites branch participation in the review process. Please follow the instructions listed on the review report for a non-concur of the eligibility decision.
23. Why is the error for only one person when there are others on the case? PERM reviews are a federal requirement, and under their guidelines, case reviews are completed for an individual beneficiary. The information provided to the branch is for the beneficiary under review, but branch staff are encouraged to review the information as it may pertain to other members of the benefit group |
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