CMS-10191 ODAG GRV 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 Remediation Initiated
(MM/DD/YY)

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

Cardholder ID

Contract ID

Plan ID

Time grievance/
Date grievance/
complaint was received
complaint was
(expedited only)
received
(HHMMSS- Military
(MM/DD/YY)
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; Organization 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)

If an extension was taken,
Time oral notification
Description of the
Date oral notification
did the plan notify the
Date written notification of Time written notification
If appeal or organization determination
resolution (ensure text
member of the reason(s) provided to enrollee (if no provided to enrollee (if no
of resolution provided to
request was included with the grievance,
resolution provided to
oral notification, please
field is formatted so text
oral notification, please
for the delay and of their
enrollee
enrollee
date of member outreach
indicate N/A)
wraps and the entire field
indicate N/A)
right to file an expedited
(HHMMSS- Military time)
(MM/DD/YY)
(MM/DD/YY)
(HHMMSS- Military time)
is readable)
(MM/DD/YY)
grievance?
(Y/N/NA)

If sponsor offered member the
opportunity to file an appeal, did the
member accept
(Y/N/NA= sponsor did not offer an
appeal)

Date of appeal
(N/A Sponsor did not offer the
opportunity to file an appeal or member
declined opportunity)
(MM/DD/YY)

Description of the appeal disposition
Date of appeal disposition
(request approved/denied on reconsideration)
(MM/DD/YY)

Time of appeal
disposition
(HHMMSSMilitary time)