CMS-10630 Appeals Impact Analysis Template

OMB Control Number: 0938-TBD (Expires: TBD)

Date Identified
(MM/DD/YY)
(Completed By The CMS
Audit Lead)

Detailed Description of the Issue
Brief Description Of Issue
(Completed By The CMS Audit Lead)

Condition Language
(Completed By The CMS Audit Lead)

(Explain what happened)
(Remaining fields to be Completed by PACE
Organization)

Root Cause Analysis for the Issue
(Explain why it happened)

Methodology - Describe the process that was
undertaken to determine the # of individuals
(e.g. participants) impacted

# of Individuals
Impacted

Action 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
Individuals Including Outreach Description and Status

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

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

Participant
First Name

Participant Last
Name

Participant ID

Date Request
Initially
Received.
(MM/DD/YY)

Time Request
Initially
Received.
(HH:MM:SS)

Date Appeal
Initiated.
(MM/DD/YY)

Time Appeal Initiated.
(HH:MM:SS)

Reason for
Extension.

Was the Reason for
the Extension
Documented?
(Y/N)

Did the PO Notify
the Participant
Regarding the
Extension? (Y/N)

What Services
Were Being
Disputed?

Did the PO Provide the
Disputed Services to the
Was the Participant a
Medicaid Participant During
Medicaid
the Appeal?
Participant? (Y/N)
(Y/N)

Was the Reviewer an
Impartial Third Party That
Was Appropriately
Credentialed? (Y/N)

Was the Reviewer
Involved in the Initial
Decision? (Y/N)

Reviewer's
Credentials.

Were There Any
Negative Outcomes
Caused by the Failure to
Provide the Service?
(Y/N)

If Yes, Describe.

Reason for the Failure to
Provide the Service.

Has the Participant
Appealed Again?
(Medicare or
Medicaid/SAA
Process) (Y/N)

If Yes, Date of
Appeal?
(MM/DD/YY)

If Yes, What
Appeal
Process?

{Other data
requested}

{Other data
requested}

{Other data
requested}