Free Agency Position on the Payment Error Rate Measurement (PERM) Error Finding, HCF 10171 - Wisconsin


File Size: 320.2 kB
Pages: 1
Date: December 11, 2008
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHCF-BEM
Word Count: 170 Words, 1,143 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms/F1/F10171.pdf

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DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10171 (07/08)

STATE OF WISCONSIN

AGENCY POSITION ON THE PAYMENT ERROR RATE MEASUREMENT (PERM) ERROR FINDING

Complete, sign and return this form with documentation to the address below. Wisconsin Department of Health Services Division of Health Care Access and Accountability Bureau of Enrollment Management / Attn: Payment Error Rate Measurement P.O. Box 309 Madison, WI 53701-0309

CARES Case Number

Case Name

We agree with the error finding. If necessary, correct the case and submit documentation of your corrective action within 30 days. If an overpayment occurred due to client error, establish a claim to initiate benefit recovery. For error reduction initiatives, what information from the client, agency or state would have helped prevent this error? Please respond within 30 days.

We disagree with the error finding. Provide additional information and/or documentation to explain why you feel the eligibility determination was correct. Please respond within 14 days.

SIGNATURE ­ Agency Representative

Title/Position

Date Signed

AGENCY NAME