CMS-10630 Appeals Impact Analysis Template

Audit Review Period:
Issue of non-compliance:

Expedited appeal extensions

Scope:

Review all of the expedited appeals processed during the audit review period.

Instructions:

• Review all of the expedited appeals processed during the audit review period and respond to the questions in the participant impact tab.
• The review timeframe is the audit review period. Errors noted prior to the audit review period should not be included.
• After completing the Impact Analysis, if any changes need to be made to the Root Cause Analysis, please update the changes in the RCA tab.

Impact Analysis Due Date:

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)

Pending OMB Approval (0938-New)

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

Pending OMB Approval (0938-New)

# of Individuals
Impacted

Action Taken to Resolve System/
Operational Issues

Date System/ Operational Remediation Date System/ Operational Remediation Actions Taken to Resolve Negatively Impacted Individuals Date Individual Outreach and Remediation
Completed (MM/DD/YY)
Including Outreach Description and Status
Initiated
Initiated
(MM/DD/YY)
(MM/DD/YY)

Pending OMB Approval (0938-New)

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

Participant First Name

Participant Last Name

Participant ID

Date of Enrollment

Date of Disenrollment

MM/DD/YYYY

MM/DD/YYYY

Pending OMB Approval (0938-New)

Service/Item being Appealed

Date the expedited appeal was requested.

Was the expedited appeal extended?

MM/DD/YYYY

(Yes/No)

Did the participant/participant
representative request an extension?
(Yes/No)
If the appeal was not extended, enter NA.

Pending OMB Approval (0938-New)

Did the PO justify to the State administering agency the
need for additional information and how the delay is in
the interest of the participant?
(Yes/No)

Enter the date PO responded to the
expedited appeal.
MM/DD/YYYY

Optional: Please note, you do not have to complete this column.
If there are any mitigating factors that you would like CMS to consider related to a
specific appeal, please enter the information in this column.

If the appeal was not extended, enter NA.

Pending OMB Approval (0938-New)