CMS-10630 Clinical Appropriateness for Providers Impact Analysis T

OMB Control Number: 0938-TBD (Expires: TBD)
Date Identified
(MM/DD/YY)
(Completed By The CMS Audit
Lead)

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

Condition Language
(Completed By The CMS Audit
Lead)

Detailed Description of the Issue
(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

Type of Service.

Number of Available
Providers.

Reason the Provider Was
Were There Any
Not Available to
Negative Outcomes?
Participant?
(Y/N)

If Yes, What Were the
Negative Outcomes?

{Other Data
Requested}

{Other Data
Requested}

{Other Data Requested}