CMS-10191 SNP-MOC Training 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 #
impacted

Member Impact
Y/N

Member Impact Details
(Access to Care, Delayed Care,
etc.)

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 Issues, Including Outreach Description
and Status

Date Outreach and Remediation
Initiated (MM/DD/YY)

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

Cardholder ID
(If member impact)

Beneficiary Name
(If member impact)

Contract ID

Plan ID

Plan Type

Provider/Staff/ICT
Name

MOC Training Date

Next Training
Due Date

Provider/Staff/ICT
Involvement with Member
Care/Coordination
(Describe)

MOC Processes Impacted (HRA,
ICT, and/or ICP completion, etc.)

Sponsor's Clarifying Comments
(if applicable)