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PERM Frequently Asked Questions (FAQs)

 

PERM at Oregon DHS

 

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Provider FAQs

 

Claims

  1. When will Oregon’s review start?
  2. How many claims will be reviewed during the PERM review? 
  3. I’ve sent claims to Oregon Medicaid. How does this affect me? 
  4. If one of my claims is chosen for review, how long do I have to return the documentation?
  5. What if an overpayment is discovered on one of my paid claims? 
  6. One of my claims was determined to have an error and I want to appeal the decision. What do I need to do? 
  7. How will patient privacy be maintained? 

Eligibility

  1. I am a caseworker. How does PERM apply to me? 
  2. When will Oregon’s eligibility review start?
  3. Who is going to conduct the PERM eligibility reviews? 
  4. How many cases will be reviewed during the PERM review? 
  5. Will I be notified if an error is discovered with one of my cases? 
  6. One of my cases was determined to have an error and I want to appeal the decision. What do I need to do? 
  7. Why is the error for only one person when there are others on the case? 

 


 

Claims

 

1. When will Oregon’s review start?

Starting in January 2011, Oregon’s Medicaid and the Children's Health Insurance Program will begin sending claims data and copies of all related state policies to a federal contractor. The claims data will reflect claims submitted to Oregon during the Federal Fiscal Year 2011 (October 1, 2010 to September 30, 2011).

 

 

2. How many claims will be reviewed during the PERM review?

CMS considers the error rate from the state's previous PERM cycle to determine the state's annual sample size for the current PERM cycle. The maximum sample size is set at 1,000 claims for each component.

 

 

3. I’ve sent claims to Oregon Medicaid. How does this affect me?

If you 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 with correct codes.

 

 

4. If one of my claims is chosen for review, how long do I have to return the documentation?

Providers have 75 days to submit required documentation. The rules for submitting documentation fluctuate depending on whether or not the provider sent in everything the first time. If a provider sends partial documentation, they only get another 14 days to send the rest of the documents even if they have 40 days left from the original 75-day timeframe. Seventy-five days does not always mean 75 days.

 

If the documentation submitted is insufficient, the review contractor will request additional documentation. The provider has a new timeframe of 14 calendar days to submit the additional documentation. The 14 days is not an extension of the original 75-day timeframe, even though it is still within the 75-day period.

 

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 75 days. If you do not provide the documentation within the required timeframe, the claim will be cited as an erroneous payment and the state will pursue recovery of payment for the claim.

 

 

5. What if an overpayment is discovered on one of my paid claims?

If an overpayment is discovered, the provider must return the overpayment to the state within 60 days of identification of the overpayment. The state will pursue recovery of the improper payment from the provider. The state is required to return to CMS the federal share of any overpayment.

 

 

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 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.

 

  

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 CMS contractor.

 

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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 2010 for the 2011 Federal Fiscal Year (October 2010 to September 2011). 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 CHIP 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.

 


13. One of my cases was determined to have an error and I want to appeal the decision. What do I need to do?

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 is encouraged to review the information as it may pertain to other members of the benefit group.

 

 


 

 

Where can I get more information on PERM?
You can find more information on the Centers for Medicare and Medicaid Services (CMS) Web site: www.cms.hhs.gov/PERM/

 

What if I have more questions?
Please e-mail your questions about PERM to opar.oregonperm@state.or.us