Medicare Parts C and D Universal Audit Guide

Attachment VII - A

1

2

3

CMS
Beneficiary Beneficiary Contract
Name
HICN
ID

4

CMS
Plan ID

5

Date the request
was received

6

Time the request
was received

7

Diagnosis

8

Issue Description -- List type of service
(e.g., SNF/HH/PT/OT) and level of
service (e.g.,
inpatient/outpatient/ER/urgent care);
ensure text field is formatted so text
wraps and the entire field is readable

9

Y/N Flag to indicate if the
OD was processed under
expedited timeframe

10

11

Y/N Flag to indicate if a
timeframe extension was taken.
Y/N Flag to indicate if a determination was requested under If Y: Was member notified of the
the expedited timeframe but the plan determined expediting reasons for the delay & of their
right to file an expedited
was unnecessary and instead processed the case under the
standard timeframe
grievance?

12

Date approved--plan level

13

Time approved--plan level

14

15

Date oral
notification
provided to
enrollee (if
no oral
notification,
indicate N/A)

Time oral
notification
provided (if
no oral
notification,
indicate N/A)

16

Date written
notification
provided to
enrollee

17

Time written
notification
provided to
enrollee

18

Date effectuated
in plan's system

19

Time effectuated
in plan's system

20

Was timely
notification
provided to the
enrollee (or
representative)?

21

22

Was the decision
effectuated in
Was timely
the plan's system
notification
within the
provided to the
provider/physician if effectuation
timeframe?
applicable?
Pass/Fail

23

Comments

24

Condition

25

Criteria

26

Cause

27

Effect