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