CMS-10191 ODAG DIS 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
(enter NA if
not available)

Person who
made the
request (CP,
NCP, B, BR)

Type of Request
(grievance, pre-service
OD, pre-service
Time the request was
Provider Type Date the request was
Is this an expedited or standard Date the request was dismissed Time the request was dismissed Reason for Dismissal (e.g., no
reconsideration, NCP
recieved (HHMMSS - Issue Description
request (E/S)
(MM/DD/YY)
(HHMMSS - Military time)
AOR, no WOL, untimely filing)
(CP/NCP/NA) received (MM/DD/YY)
Military time)
claim, DMR, NCP
reconsideration, DMR
reconsideration)

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

Time written notification
provided to
enrollee/provider
(HHMMSS - Military
time)

Appealed to IRE
(Y/N)

Date forwarded to
IRE (MM/DD/YY)

If plan directed
care, amount of
enrollee liability
($)

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

If enrollee paid,
amount ($)

Amount enrollee
reimbursed ($)

Date enrollee
reimbursed
(MM/DD/YY)