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PERM Frequently Asked Questions (FAQs)

 

PERM at Oregon DHS


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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. FY2014-FY2016 Medicaid and CHIP Eligibility Review Pilots

 


 

Claims

 

1. When will Oregon’s review start?

Starting in January 2014, 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 2014 (October 1, 2013 to September 30, 2014).

 

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. FY2014-FY2016 Medicaid and CHIP Eligibility Review Pilots

In light of the changes to the way states adjudicate eligibility for applicants for Medicaid and CHIP implemented by the Affordable Care Act, the State Health Official Letter 13-005 issued on August 15, 2013 directs states to implement Medicaid and CHIP Eligibility Review Pilots in place of the Payment Error Rate Measurement (PERM) and Medicaid Eligibility Quality Control (MEQC) eligibility review requirements for fiscal years (FY) 2014-2016.  The Medicaid and CHIP Eligibility Review Pilots will provide more targeted, detailed information on the accuracy of eligibility determinations using the Affordable Care Act’s rules, and provide states and CMS with critical feedback during initial implementation.  

The eligibility review pilots will provide a testing ground for different approaches and methodologies for producing reliable results and help inform CMS’s approach to rulemaking that it will undertake prior to the resumption of PERM eligibility measurement component in FY 2017.

  • ​All states will participate annually as a means to ensure that there are no gaps in oversight during this transition period.

  • States will be conducting four streamlined pilot measurements over the three year period and results will be reported to CMS in June 2014, December 2014, June 2015 and June 2016.

  • States will submit project descriptions and sampling approaches to CMS for expedited approval as directed in CMS guidance.


 

 

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