CMS-10191 CDAG CDM Impact Analysis

Date Issue Identified
(MM/DD/YY)
(Completed By The
CMS Team Lead)

Brief Description Of Issue
(Completed By The CMS Team Lead)

Condition Language
(Completed By The CMS Team Lead)

Related to Pre-Audit Issue
Pre-Audit Issue Summary
Summary?
Number
(Completed By The CMS Team (Completed By The CMS
Team Lead)
Lead)
(If applicable)
(Y/N)

Detailed Description of the Issue
(Explain what happened)
(Remaining fields to be completed by Sponsor)

Root Cause Analysis for the Issue
(Explain why it happened)

Methodology - Describe the
process that was undertaken to
determine the # of members
impacted

# of Drugs Affected

List Of Drugs Affected

# of Members
Impacted

Actions Taken to Resolve System/Operational
Issues

Date System/Operational
Remediation Initiated
(MM/DD/YY)

Date System/Operational
Remediation Completed
(MM/DD/YY)

Actions Taken to Resolve Negatively Impacted Beneficiaries
Including Outreach Description and Status

Date Beneficiary Outreach and
Remediation Initiated
(MM/DD/YY)

Date Beneficiary Outreach and
Remediation Completed
(MM/DD/YY)

GPI 14 or GCN

NDC
(11 digits; no hyphens or spaces)

RxCUI

Drug Name

Number of Impacted
Members

Protected Class
(Y/N)

Cardholder ID

Contract ID

Plan ID

Effective Date of
Enrollment
(MM/DD/YY)

Is beneficiary
currently
enrolled?
(Y/N)

GPI 14 or GCN

NDC
(11 digits; no hyphens or
spaces)

Drug Name

Request type CD or RD

Expedited CD or
RD?
(Y/N)

Date request was
received
(MM/DD/YY)

Time request was
Was the request
received
(HHMMSS- Military approved or denied?
time)

Date request was
approved/denied
(MM/DD/YY)

Date of written
notification
(MM/DD/YY)

If decision or
Number of hours
Number of hours
Did beneficiary ever receive the originally
notification was
Time of written
decision/effectuation
Dates of adjudicated
If yes in column V, indicate Date issue was resolved
Brief summary of issue resolution
notification untimely
requested medication as evidenced by a
untimely, was the
notification
untimely
or remediated
claims after decision date
number of elapsed days from
(e.g. new notification letter and reason, prescriber contact
(N/A if not
paid claim?
(HHMMSS- Military case forwarded to the
(N/A if not
(MM/DD/YY)
(MM/DD/YY)
date of receipt of request.
and outcome, beneficiary received medication)
IRE?
applicable)
(Y/N)
time)
applicable)
(Y/N)

If approval was not granted, provide brief explanation
(ex: outreach to MD showed member is on similar
medication and no longer needs the medication)

Request type
(e.g., tiering exception; non-formulary exception; Part B vs.
Part D; DMR; Other)