CMS-10630 Clinical Appropriateness for Emergencies Impact Analysis

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

If Participant Went to the
If Hospitalized, Most Recent Date of
Emergency Room, Most Recent
Hospitalization.
Date of the Emergency Room Visit.
(MM/DD/YY)
(MM/DD/YY)

The Reason(s) or
Symptom(s) that
Caused the
Participant or
Caregiver to Seek
Emergency
Services.

Did the Participant or Caregiver
Contact the PO Before Seeking
Emergency Care?
(Y/N)

Was Emergency Care Provided?
(Y/N)

Where Was the Emergency Care
Provided?

Date Emergency Care Was Provided.
(MM/DD/YY)

Time the Emergency Care Was
Provided.
(HH:MM:SS)

Was the Participant Held Harmless
for Utilization of Emergency Care
Services?
(Y/N)

{Other Data
Requested}

{Other Data
Requested}