CMS-10630 Service Delivery Request and Appeals Impact Analysis Tem

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

Scope:

Auditors:
Select All that Apply

Issue
Provision of services following an approved service delivery request
Provision of services to Medicaid participants during an appeal
Provision of services following an approved appeal

Provision of services following an approved service delivery request:
• All service delivery request approvals during the audit review period.
Provision of services to Medicaid participants during an appeal:
• All appeals during the audit review period.
Provision of services following an approved appeal:
• All approved appeals during the audit review period.

Instructions:

General:
• 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.
Provision of services following an approved service delivery request:
• Review each service delivery request approval during the audit review period and respond to the questions in the Participant Impact tab.
Provision of services to Medicaid participants during an appeal:
• Review each appeal to determine if the participant requested to continue the service during the appeal.
• If the participant was enrolled in Medicaid, answer all of the remaining questions. If the participant was not enrolled in Medicaid, answer NA to all of the remaining questions.
Provision of services following an approved appeal:
• Review each approved appeal 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

MM/DD/YYYY

Service/Item Requested

Enter NA if the participant is still
enrolled.

Pending OMB Approval (0938-New)

This information is to be completed if the Impact Analysis is being requested for: Provision of services following an approved service delivery request
Date the service delivery request was received by IDT.

Was the request approved in full by the IDT?

MM/DD/YYYY

Date oral/written notification of the
approval was provided to the
participant/participant representative. If
oral and written notification were
If the auditor did not select Provision of services following provided, enter the earliest date.
an approved service delivery request on the instructions
tab the PO may enter NA in fields G-N.
MM/DD/YYYY

Enter Yes if approved in full.
Enter partially approved if the approval was not as the
participant requested (modified approval or a compromise
was offered).

If modified or partial approval, what was
the approved service?

Was the service provided as approved by
the IDT?

Date the service was provided to the
participant.

Enter NA if approved in full.

(Yes/No)

Enter NA if the service was not provided.
MM/DD/YYYY

Enter NA is notification was not rendered
to the participant.

Pending OMB Approval (0938-New)

What evidence/documentation does the
Did the participant experience any negative
PO have that demonstrates the service was outcomes between the date the service
provided?
was approved and the date that the service
was provided?
Enter NA if the service was not provided to
the participant.
(Yes/No)

This information is to be completed if the Impact Analysis is being requested for: Provision of services to Medicaid participants during an appeal
Was the participant enrolled in Medicaid? This includes participants who are Date the appeal was received by the PO.
Medicaid only and dual eligible.
MM/DD/YYYY
(Yes/No)
If the auditor did not select Provision of services to Medicaid participants
during an appeal on the instructions tab the PO may enter NA in fields O-X.

Was the appeal related to a termination or Did the participant request to continue the Was the service continued during the
appeal process?
reduction in services that were currently
service during the appeal process?
being furnished to the participant?
(Yes/No)
(Yes/No)
(Yes/No)

If the participant requested to continue the Was the service approved, denied or
service and the service was not continued, partially denied by the third-party
please enter the date the service was
reviewer?
terminated. Enter NA if the participant did
not request to continue the service.
MM/DD/YYYY

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

Pending OMB Approval (0938-New)

If the service was terminated and the
service was approved by the third-party
reviewer, enter the date that the service
resumed.
MM/DD/YYYY
Enter NA if the service was denied by the
third-party or the service was never
terminated.

What evidence or documentation does the If the participant requested to continue the
PO have to show the service was provided? service and the service was not continued,
were there any negative participant
Enter NA if the service was not provided.
outcomes?
(Yes/No)

This information is to be completed if the Impact Analysis is being requested for: Provision of services following an approved appeal (enter all appeals that were approved at any level of the appeal (e.g., third party reviewer, Medicaid State Fair Hearings, IRE, etc.)
Date the appeal was received by IDT.
MM/DD/YYYY
If the auditor did not select Provision of
services following an approved appeal on
the instructions tab the PO may enter NA in
fields Y-AG.

Description of the item/service being
appealed.

Date the appeal was approved by any
appeal entity (e.g., third party reviewer,
IRE, State fair hearings, etc.).

Entity that approved the appeal.
(Third Party Reviewer, IRE, State Fair
Hearings, etc.)

Was the final decision Approved or Partially If partially approved/denied, what was the If the service was approved or partially
Approved/Denied?
approved portion of the item or service?
approved by either the third-party,
Medicaid, or Medicare reviewer, enter the
Enter NA if the appeal was approved in full. date that the service was provided or
resumed.
MM/DD/YYYY
Enter "Not Provided" if the approved
service was not provided or if there is no
evidence the approved service was
provided.

Pending OMB Approval (0938-New)

What evidence or documentation does the Did the participant experience any negative
PO have to demonstrate that the approved outcomes between the date the service
service was provided?
was approved and the date that the service
was provided? Enter NA if the service was
Enter NA if the approved service was not
denied.
provided.
(Yes/No)

General Information: This information is to be completed for all Impact Analyses
If the participant experienced any negative outcomes, please describe the negative
outcomes.
Enter NA if there were no negative outcomes.

If the participant experienced negative
Optional: Please note, you do not have to complete this column.
outcomes, did they occur, in some part, as a
result of the failure to provide the item or 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.
service?
(Yes/No)
Enter NA if there were no negative
outcomes

Pending OMB Approval (0938-New)