CMS-10191 SNP-MOC ICP ICT Impact Analysis

Date Identified
(MM/DD/YY)
(Completed by
Team Lead)

Brief Description Of Issue (Completed by Team Lead)

Condition Language (Completed by
Related to Pre-Audit Issue Summary?
Team Lead)
(Y/N) (Completed by Team Lead)

Detailed Description of the Issue
Pre-Audit Issue Summary
(Explain what happened)
Number (Completed by
(Remaining fields to be Completed By The Part
Team Lead)
C Sponsor)
(If Applicable)

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

Beneficiary Name

Contract ID

Plan ID

Plan Type

Effective Date of
Enrollment
(MM/DD/YY)

Was an HRA
Conducted?
(Y/N)

If an HRA Was
Conducted, Were
Needs Identified?
(Y/N)

If an HRA Was Conducted and
Needs Were Identified, Was an
ICP Created? (Y/N)

If an ICP Was
Created, Were the
Identified Needs
Addressed? (Y/N)

Was an ICT
Created?
(Y/N)

Were ICT
Is There Evidence That the PCP
Meetings
Was Invited to Participate on the
Conducted at
Beneficiary's ICT? Y/N
Least Annually?
(Y/N)