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Reporting Year 2021 PERM Review: Medical Record Requests Initiated

Last updated on 1/27/2021

Texas is currently participating in the Payment Error Rate Measurement (PERM) review, which began in the spring of 2020. The review includes Texas Medicaid and the Children’s Health Insurance Program (CHIP) claims paid from July 1, 2019, through June 30, 2020.

The Centers for Medicare & Medicaid Services (CMS) initiated PERM to measure the accuracy of Medicaid and CHIP payments. CMS utilizes two contractors, the Lewin Group and NCI, Inc. (NCI), to select and review Texas Medicaid and CHIP claims for programs administered by the Health and Human Services Commission (HHSC) and the Department of State Health Services (DSHS).

The Lewin Group selected claims at random, and NCI is currently reviewing the selected claims. State health-care program providers must participate in the PERM review and must provide medical record documentation that supports the payment made for each claim that is selected for review.

Methods of Provider Notification

If a claim is selected for review, providers receive a series of communications, including the following:

  • A TMHP or HHSC representative will call the provider to verify contact information such as the provider’s mailing address and fax number.
  • A NCI representative will call the provider to ask whether he or she prefers to receive the review notice by fax or U.S. mail.
  • A NCI representative will send the review notice with the selected claim(s) and request copies of the supporting records for each claim.

Deadlines for Providing Requested Medical or Pharmacy Records

Providers must submit the requested information to NCI within 75 calendar days of receipt of the written request from NCI. If NCI requests additional information, the provider must submit the requested information to NCI within 14 calendar days of the receipt of the written request.

Important: If a provider fails to respond or produce complete and correct documentation for a selected claim within the period indicated in the notice, NCI will identify the claim as a PERM exception, and the provider must reimburse the total amount paid for the claim in accordance with state and federal requirements.

Providers are encouraged to ask questions about the request for information as soon as possible. This will help prevent a PERM exception for failing to respond in a timely manner with complete and accurate information. Providers with questions about the records request should contact NCI customer service representatives at 800-393-3068 immediately.

The overall error rate is adversely affected when providers fail to provide complete documentation in response to PERM requests. Texas Medicaid appreciates all provider support of the PERM process. Providers are encouraged to monitor this website for additional PERM information in future publications.