CMS10191 MTM 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?
(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)
(This and 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

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)

Cardholder ID

Contract ID

Plan ID

Effective date of
contract
enrollment
(MM/DD/YY)

MTM Program eligibility
determination date
(MM/DD/YY)
(NONE if not determined
eligible)

MTM Program
enrollment date
(MM/DD/YY)
(N/A if not
applicable)

Continuing
MTM Program
member?
(Y/N)

Beneficiary
identified as
cognitively
impaired?
(Y/N)

Date identified as
cognitively
Beneficiary identified as long
impaired?
term care resident at the time
(MM/DD/YY)
CMR offered or administered?
(Y/N)
(N/A if not
applicable)

MTM Program
opt-out date
(MM/DD/YY)
(N/A if not
applicable)

MTM Program
opt-out reason
(N/A if not
applicable)

MTM Program opt-out
method
(Phone/Fax/Mail/
Email/Text/Other) (N/A
if not applicable)

Date CMR offered
(MM/DD/YY)
(N/A if not applicable, NONE if no
CMR offered for member enrolled in
MTM program)

CMR delivery method
(N/A if not applicable)

Date CMR declined
Method CMR declined
(MM/DD/YY)
(Phone/Fax/Mail/
Email/Text/Other) (N/A if
(N/A if not
not applicable)
applicable)

Provider type(s) administering
CMR
(N/A if not applicable)

Date CMR written summary
provided
(MM/DD/YY)
(N/A if not applicable, NONE if no
summary provided)

TMR date
(MM/DD/YY)
(N/A if not applicable, NONE if no
TMR performed)

Date TMR
intervention(s)
performed
(MM/DD/YY)
(N/A if not applicable)