Data processing examines a random sample of Medicaid and Children's Health Insurance Program (CHIP) fee-for-service, managed care, and waiver program payments. The Centers for Medicare and Medicaid Services (CMS) Payment Error Rate Measurement (PERM) reviewers look for potential issues such as:

• Data entry errors (for example, incorrect dates or units)
• Payment for non-covered services
• Duplicate payments
• Use of incorrect payment method (for example, fee-for-service payment for managed care enrollee; fee-for-service payment for waiver program participant)
• Incorrect payment coordination with other insurers (for example, Medicare, private insurance, Tricare)
• Payment pricing errors (fee-for-service and managed care capitation)
• Incorrect system edit and audit functions

Medical review examines a sample of Medicaid and CHIP fee-for-service and waiver program payments that are part of the data processing sample.

A CMS contractor will request medical records from providers and review that information to determine if the service was necessary and that all applicable ForwardHealth policies, procedures, and regulations related to that service were both appropriately documented and provided.

Centers for Medicare and Medicaid Services PERM reviewers evaluate whether a provider:

• Provided documentation within the required time frame
• Supplied documentation that supported the reimbursed service
• Submitted the correct procedure/service code for what was paid and documented
• Used the correct diagnosis code
• Billed the correct number of service units
• Provided only necessary services
• Provided services that meet ForwardHealth policies, regulations, or other requirements

The Wisconsin Department of Health Services' (DHS) Income Maintenance Quality Control (IMQC) section of the Bureau of Enrollment Policy and Systems oversees Wisconsin's PERM member enrollment quality reviews for Medicaid and CHIP in partnership with the federal government.

The IMQC section is currently in the PERM review cycle for member enrollment for Fiscal Year (FY) 2018. Information about the PERM eligibility review is communicated via state-issued Operations Memos that establish statewide processes for executing eligibility policy.

In the PERM process, sampled member enrollment case files are reviewed to determine that enrollment was correctly granted, denied, or terminated in accordance with all federal and state regulations, State Plans, and DHS policies and procedures.