CMS-10630 Appeals Impact Analysis Template

Audit Review Period:
Issue(s) of non-compliance:

Scope:

Auditors:
Select All that Apply

Issue
Categorizing Appeals
Appeals Reviewers
Presenting Evidence During Appeals
Medicaid and Medicare Appeal Rights

Categorizing Appeals:
• Review all denied service delivery requests during the audit review period.
Appeal Reviewers:
• Review all of the appeals processed during the audit review period.
Presenting Evidence During Appeals:
• Review all of the appeals processed during the audit review period.
Medicaid and Medicare Appeal Rights
• Review all of the appeals processed during the audit review period.

Instructions:

General:
• If there have been any changes to the Root Cause Analysis, since the original Root Cause Analysis was provided, please update the changes in the RCA tab.
• 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.
Categorizing Appeals:
• Review the medical record for each participant who had a service delivery request denial to determine if the participant requested an appeal.
• Respond to the questions in the Participant Impact Tab.
Appeal Reviewers:
• Review all of the appeals processed during the audit review period and respond to the questions in the Participant Impact tab.
Presenting Evidence During Appeals:
• Review all of the appeals processed during the audit review period and respond to the questions in the Participant Impact tab.
Medicaid and Medicare Appeal Rights
• Review all of the appeals processed during the audit review period and respond to the questions in the Participant Impact 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)

General Information: This information is to be completed for all Impact Analyses
Participant First Name

Participant Last Name

Participant ID

Date of Enrollment

Date of Disenrollment

MM/DD/YYYY

Enter NA if the participant is still
enrolled.

Service/Item being Appealed

Pending OMB Approval (0938-New)

This information is to be completed if the Impact Analysis is being requested for: Categorizing Appeals
Did the participant request an appeal during the audit review period (or
appeal/challenge a denied service delivery request)?
(Yes/No)
If the auditor did not select Categorizing Appeals on the instructions tab the PO
may enter NA in fields G-O.

Date the request for the appeal was received.
MM/DD/YYYY

Was the service/item being appealed originally
processed as a service delivery request?

Was the request for an appeal reviewed by a thirdparty reviewer?

Was the request/appeal/challenge ever resolved?
(Was a decision ever rendered?)

If the appeal/request/challenge was resolved, date of Was the participant ever provided the disputed
resolution/decision.
service/item?

If the participant was provided the item/service, what What evidence is there to demonstrate that the
was the date that service was provided?
service was received?

(Yes/No)

(Yes/No)

(Yes/No)

MM/DD/YYYY

MM/DD/YYYY

Enter NA if the appeal was not resolved.

If the answer to this question is No the PO may enter NA in fields H-O.

Pending OMB Approval (0938-New)

(Yes/No)

Enter NA if the item/service was not provided.

Enter NA if the item/service was not provided.

This information is to be completed if the Impact Analysis is being requested for: Appeals Reviewers
Were any of the appeal reviewers involved in the initial decision to deny the
service delivery request?

Do any of the appeal reviewers have a stake in the
outcome of the appeal?

(Yes/No)

(Yes/No)

Enter the credentials, discipline, or licensure of each of
the 3rd-party reviewers involved in the review of the
appeal.

Was the appeal approved or denied?
Enter Approved or Denied.

If approved, what date did the participant receive the
service?

If denied, did the participant/representative request a
Medicare/Medicaid appeal?

If the participant requested another appeal, was the
external appeal approved or denied?

Enter NA if the appeal was denied.

Enter NA if the appeal was approved.

Enter NA if the appeal was approved or if the participant Enter NA if the appeal was approved or if the participant
did not request an additional appeal.
chose not to pursue additional appeal.

If the auditor did not select Appeals Reviewers on the instructions tab the PO may
enter NA in fields P-W.
If the answer to this question is No the PO may enter NA in fields Q-W.

Pending OMB Approval (0938-New)

What was the date of the external Medicare/Medicaid
decision?

This information is to be completed if the Impact Analysis is being requested for: Presenting Evidence During Appeals
Did the PO provide written notification to the participant/participant
representative that included the participant/participant representative's right to
present evidence related to the dispute in person?
(Yes/No)
If the auditor did not select Presenting Evidence During Appeals on the
instructions tab the PO may enter NA in fields X-AE.

Did the PO provide written notification to the participant/participant
representative that included the participant/participant
representative's right to present evidence related to the dispute in
writing?

Enter the date written notification was provided to the
participant/participant representative.

Did the participant/participant representative request to present
evidence related to the dispute in person?

Did the participant/participant representative request to present
evidence related to the dispute in writing?

MM/DD/YYYY

(Yes/No)

(Yes/No)

(Yes/No)

Enter NA if the participant/participant representative did not receive
written notification.

Pending OMB Approval (0938-New)

Was the participant/participant representative given an opportunity to Was the participant/participant representative given an opportunity to Enter the date PO responded to the appeal.
present evidence related to the dispute in person?
present evidence related to the dispute in writing?
MM/DD/YYYY
(Yes/No)
(Yes/No)
Enter NA if there was no response to the appeal.
Enter NA if the participant/representative did not request to present Enter NA if the participant/representative did not request to present
information in person.
information in writing.

This information is to be completed if the Impact Analysis is being requested for: Medicaid and Medicare Appeal Rights
Enter the date of the appeal decision.
MM/DD/YYYY
If the auditor did not select Medicaid and Medicare Appeal Rights on the
instructions tab the PO may enter NA in fields AF-AL.

Was the service/item being appealed approved or denied by the third-party
reviewer?
Enter Approved or Denied.

General Information: This information is to be completed for all Impact Analyses
For denials, did the PO provide written notification to the
participant/participant representative informing them of their appeal rights
under Medicare and Medicaid?
(Yes/No)
Enter NA if the service being appealed was approved.

Did the participant/participant representative request to pursue their appeal
rights under Medicare and Medicaid?

Did the PO provide assistance to the participant/participant representative in
choosing which appeal rights to pursue?

(Yes/No)

(Yes/No)

Enter NA if the service being appealed was approved.

Enter NA if the service being appealed was approved or if the
participant/participant representative chose not to pursue additional appeals.

Pending OMB Approval (0938-New)

Did the PO forward the appeal to the appropriate external entity?

Enter the date the appeal was forwarded to Medicare, Medicaid, or Both.

Optional: Please note, you do not have to complete this column.

(Yes/No)

MM/DD/YYYY

Enter NA if the service being appealed was approved or if the
participant/participant representative chose not to pursue additional appeals.

Enter NA if the service being appealed was approved or if the
participant/participant representative chose not to pursue additional appeals.

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.