Claims Review
For the claims review, each state submits quarterly “universe data” to the CMS Contractor. Universe data files are essentially very long “lists” of nearly all Medicaid and CHIP beneficiary-specific payment records adjudicated by a state during the quarter. States compile PERM universe files from MMIS systems, data warehouses, HIPP payment files, county and state agency systems, vendor payment systems, managed care files, and a variety of other sources. States then divide their PERM universe data into four program areas:
PERM Claims Program Areas |
Medicaid
fee-for-service |
CHIP
fee-for-service |
Medicaid
managed care |
CHIP
managed care |
Eligibility Review
The purpose of the eligibility review is to verify beneficiary eligibility not the caseworker’s actions. Eligibility reviewers look to the beneficiary’s categorical and financial eligibility.
For active case reviews, a case is correct if the beneficiary is determined “eligible” and is in error if the beneficiary is determined “ineligible.” Active cases are considered “undetermined” if eligibility cannot be verified with documentation provided or obtained. The "undetermined" cases are included in the national and state error rates. Negative cases are reviewed to determine if applicants and beneficiaries are denied or terminated in error.
Cases denied or terminated in error should be referred back to the agency responsible for the eligibility determination for a redetermination for benefits. Eligibility reviews are completed in two program areas:
PERM Eligibility Program Areas |
Medicaid eligibility |
CHIP eligibility |
When the review is completed, CMS computes and publishes a national and a state annual PERM report with a breakdown of error rates and findings.
Want more details? Please see our Frequently Asked Questions.