CMS-10191 ODAG PMNT 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

Claim Number

Contracted or noncontracted provider

Date the request
was received
(MM/DD/YY)

Diagnosis

Issue Description -- List type of service (e.g., SNF/HH/PT/OT)
and level of service (e.g., inpatient/outpatient/ER/urgent care);

Date denied
(MM/DD/YY)

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

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

If the non-contract
Did the non-contract
provider billed the
provider bill the
enrollee, the amount ($)
enrollee?
billed
(Y/N)

If the non-contract
provider billed the
enrollee, the amount
($) the enrollee paid

Date enrollee paid
Amount enrollee paid
amount reimbursed to
reimbursed to
enrollee
enrollee
(MM/DD/YY)

Date affected non-contract providers
were provided a description of the
appeals process and notice
containing the elements cited in
MMCM Ch. 13, Sec 40.2.3
(MM/DD/YY)