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PERM Frequently Asked Questions (FAQs)
Claims
Eligibility
Claims
1. 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 Federal Fiscal Year 2008 (October 1. 2007 through September 30, 2008).
2. How many claims will be reviewed during the PERM review? Approximately 3,000 Oregon Medicaid claims, fee-for-service and Managed Care, will be reviewed for Federal Fiscal Year 2008. About 500 claims will be reviewed each quarter (October 1. 2007 through September 30, 2008).
3. I’ve sent claims to Oregon Medicaid. How does this affect me? If you are a non Managed Care provider and have submitted a claim to Oregon, you may be randomly selected for review. If you are selected, 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.
4. If one of my claims is chosen for review, how long do I have to return the documentation? You have 60 days to return the required documentation. You will receive a reminder letter from the contractor 15 days and 35 days after the initial request, if your information has not been received. Documentation that is incomplete or inaccurate may be counted as an error. Failure to send the requested documentation will be counted as an error. Please collect and return your documents right away.
IMPORTANT NOTE: If you have been asked to provide documentation for a claim please gather all documents right away. It is crucial that you respond within 60 days. Failure to send the requested documentation will be counted as an error. 5. What if an overpayment is discovered on one of my paid claims? If an overpayment is discovered on your claim, you will be contacted by the Medicaid Program Integrity Coordinator. The State of Oregon is required to return to CMS the federal share of any overpayment within 60 days of written notice by CMS (42 CFR 433.300). Recovery of overpayments in SCHIP are to be completed in time for the next quarterly expenditure report (42 CFR 457.232).
6. One of my claims was determined to have an error and I want to appeal the decision. What do I need to do? The review contractor will post monthly disposition reports of claims review findings on their website for the Medicaid Program Integrity Coordinator to review. The state will then follow up with providers to receive any needed clarifications. The states can file a notice that it disagrees with the error findings and provide supporting evidence that the claim was correctly paid. The review contractor will re-review the claim with the supporting documentation and reverse or uphold the findings. If the state disagrees with the re-review findings, there is an appeals process through CMS. For more information on the difference resolution process please see: The Difference Resolution Process [PDF, 405KB]
7. 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.
Eligibility 8. 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.
9. 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.
10. 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.
11. 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.
12. 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. The reports will be sent to each branch upon completion of the review and staffing with policy analysts. We encourage discussion within the branch on the errors cited and feedback to Quality Control is welcome.
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.
14. 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
Where can I get more information on PERM?
What if I have more questions?
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