CMS-10191 ODAG 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
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

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

Cardholder ID

Contract ID

Plan ID

Claim Number

Request typeOD or Recon

Expedited OD or
Recon?
(Y/N)

Date request was
received
(MM/DD/YY)

Time the request was
received (expedited
only)
(HHMMSS- Military
time)

Diagnosis

Issue Description -- List type of
service
(e.g., SNF/HH/PT/OT)

Level of service
(e.g., inpatient/ outpatient/
ER/urgent care)

If an OD/reconsideration was requested
under the expedited timeframe, did the plan
determine the request did not meet
expedited criteria and instead process the
OD/reconsideration under the standard
timeframe?
(Y/N/NA)

Was a timeframe extension
taken?
(Y/N/NA)

If an extension was taken, did
the plan notify the member of
the reason(s) for the delay and
of their right to file an expedited
grievance?
(Y/N/NA)

Was the request
approved or denied?

Date approved--plan level
(enter N/A if not
applicable)
(MM/DD/YY)

Time approved--plan
level (expedited only)
(HHMMSS- Military
time)

If denied, was the request
denied for lack of medical
necessity?
(Y/N/NA)

Date denied--plan
level
(MM/DD/YY)

Date oral notification
Time oral notification
Time denied--plan provided to enrollee
provided (if no oral
(if no oral
level (expedited
notification, indicate
notification, indicate
only)
N/A) (expedited only)
N/A)
(HHMMSS- Military
(HHMMSS- Military
time)
(HHMMSS- Military
time)
time)

Time written
If request denied or
notification provided
Date written
Date of receipt of
Date written
untimely, date enrollee
to enrollee
notification provided to
IRE/ALJ/MAC
notification provided
notified request has
provider
(expedited only)
decision
to enrollee
been forwarded to IRE
(HHMMSS- Military
(MM/DD/YY)
(MM/DD/YY)
(MM/DD/YY)
(MM/DD/YY)
time)

Time of receipt for
IRE/ALJ/MAC
decision (expedited
only)
(HHMMSS- Military
time)

Date effectuated
in plan's system
(MM/DD/YY)

Time effectuated
in plan's system Was interest paid on
(expedited only)
the claim?
(HHMMSS(Y/N/NA)
Military time)

Did the beneficiary
receive the
drug/service?
(Y/N)

Plan directed
If plan directed
care?
care, amount of
(Y/N)
enrollee liability ($)

Amount enrollee paid
in response to
If enrollee paid,
receiving notice of
amount ($)
liability ($)

Amount
enrollee
reimbursed ($)

Date enrollee
reimbursed
(MM/DD/YY)