CMS-10191 SNP-MOC Impact Analysis

Date 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?
(Y/N)
(Completed By The CMS Team Lead)

Pre-Audit Issue Summary
Number
(If Applicable)
(Completed By The CMS
Team Lead)

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

Beneficiary Name

Contract ID

Plan ID

Element Affected Enrollment, HRA/ICP, MOC

Effective Date of
Enrollment
(MM/DD/YY)

Initial HRA Deadline Effective enrollment
date + 90 days
(MM/DD/YY)

Initial HRA Date
(MM/DD/YY)

Audit Period
Initial HRA # of Days
Annual HRA Date
Late
(MM/DD/YY)

Prior HRA Date
(MM/DD/YY)

Annual HRA # of
Days Late

Initial ICP Date
(MM/DD/YY)

Date of Most Recent
ICP
Basis of Most Recent ICP
(MM/DD/YY)

Date of Prior
ICP Update
(MM/DD/YY)

Basis of Prior ICP

Other #1
(if applicable)

Other #2
(if applicable)

Other #3
(if applicable)

Sponsor's Clarifying Comments
(if applicable)