CMS-10191 CDAG GRV Impact Analysis

Date 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 Summary?
(Completed By The CMS Team
Lead)
(Y/N)

Pre-Audit Issue Summary Number
(Completed By The CMS Team
Lead)
(If applicable)

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 Members
Impacted

Action Taken to Resolve System/
Operational Issues

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

Date System/ Operational
Actions Taken to Resolve Negatively Impacted
Remediation Completed (MM/DD/YY) Beneficiaries Including Outreach Description and Status

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

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

Cardholder ID

Contract ID

Plan ID

Effective Date of
Enrollment
(MM/DD/YY)

Is beneficiary
currently
enrolled?
(Y/N)

Time grievance/
complaint was
Date grievance/ complaint was received
received
(MM/DD/YY)
(HHMMSS- Military
time)

How was the grievance/
complaint received
(Oral or Written)

Category of the grievance/complaint; at a minimum,
categories must include each of the following:
Enrollment/Disenrollment; Plan Benefits; Coverage
Determinations, Appeals Process; Marketing;
Confidentiality/ Privacy; Quality of Care, Expedited cases;
Fraud & Abuse; Other

Description of the grievance

Was the grievance/
complaint processed
under the expedited
timeframe?
(Y/N)

Was a
timeframe
extension
taken?
(Y/N)

Time oral notification
If an extension was taken, did the
Date oral notification
provided to enrollee
plan notify the member of the
provided to enrollee
reason(s) for the delay and of their (if no oral notification, (if no oral notification, please
indicate N/A)
right to file an expedited grievance? please indicate N/A)
(HHMMSS- Military time)
(MM/DD/YY)
(Y/N/NA)

Date written
notification of
resolution provided to
enrollee
(MM/DD/YY)

Time written
notification of
resolution provided to
enrollee
(HHMMSS- Military
time)

Brief summary of issue resolution
(e.g. new grievance letter and reason,
prescriber contact and outcome,
coverage determination initiated)

If appeal or coverage
determination request was
included with the
grievance, date of member
outreach.

Date of appeal
If sponsor offered member the
(N/A Sponsor did not offer the
opportunity to file an appeal, did the
opportunity to file an appeal or member
member accept
declined opportunity)
(Y/N/NA= Sponsor did not offer an
(MM/DD/YY)
appeal)

Description of the appeal disposition
(request approved/denied on
redetermination)

Date of appeal disposition
(MM/DD/YY)