CMS-10191 FA 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 Summary ?
(Y/N)
(Completed By The CMS Team Lead)

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

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

Cardholder ID

Contract ID

Plan ID

Effective Date of
Enrollment
(MM/DD/YY)

Is beneficiary
currently enrolled?
(Y/N)

Date of Service
(MM/DD/YY)

Date of Rejected
Claim
(MM/DD/YY)

Time of Rejected
Claim
(HHMMSSMilitary time)

GPI 14 or GCN

NDC (11 digit; no
hyphens or spaces)

Drug Name & Strength

Drug Quantity

Drug Days Supply

Processing Error Code #1:
(NCPDP reject code causing
claim to reject)

Processing Error Msg #1:
Pharmacy Messaging

Pharmacy
Error
Code #2

Pharmacy Error
Msg #2

Pharmacy
Error
Code #3

Pharmacy Error
Msg #3

Pharmacy Pharmacy Pharmacy Pharmacy
Pharmacy
Error
Error Msg
Error
Error Msg
Service Type
Code #4
#4
Code #5
#5

Number of Days
Time of
Beneficiary Went
Date of Subsequent Subsequent Paid
Without
Medication
Patient
Paid Claim - Enter Claim - Enter N/A
(Target or
Residence N/A if never received if never received
(MM/DD/YY)
(HHMMSSRelated) - Enter
Military time)
N/A if never
received

Date of Paid Claim for Time of Paid Claim for a
a Related Drug Related Drug - Enter
Related Drug NDC
Related Drug GPI 14
Enter N/A if never
N/A if never received
(11 digits; no hyphens
or GCN
or spaces)
received
(HHMMSS- Military
(MM/DD/YY)
time)

Related Drug Name &
Strength

Related Drug
Quantity

Related Drug
Days Supply

Compound Code

Ingredient
Cost (($)

Dispensing
Fee ($)

Total Drug
Cost ($)

Patient Paid
Amount ($)

Pharmacy Service
Type

Patient Residence
(e.g., LTC)