CMS-10630 Service Delivery Request Impact Analysis Template

Audit Review Period:
Issue of non-compliance:

Identifying and processing requests as service delivery requests

Scope:

• The scope of this Impact Analysis is limited to 50% of the participants enrolled during the audit review period who were not included in the provision of
services sample selection.
• The auditor will select the participants to be reviewed and enter their identifying information on the Participant Impact tab.

Instructions:

• Review only the participant medical records selected by the auditor. The selected participants are identified in the Participant Impact tab.
• Review the selected medical records to determine if the participant or participant's representative requested to initiate, eliminate, or continue a particular
service.
• Respond to the questions in the participant impact tab.
• The review timeframe is the audit review period. Errors noted before or after 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)

Did the participant or their representative
request to initiate, eliminate, or continue a
particular item or service during the audit
review period?
(Yes/No)
If No, please enter NA in all remaining
columns.

Enter the date the participant or their representative
requested to initiate, eliminate, or continue a particular
item or service.
MM/DD/YYYY

Is there documentation that the request was processed as a service
delivery request?
(Yes/No)
If there is documentation that the request was processed as a service
delivery request, and included in the SDR universe submitted to CMS,
you may enter NA in all remaining fields.

Pending OMB Approval (0938-New)

Describe the request.

If the request was not processed as a service delivery
request, was it processed/decided under a different
process?
(Yes/No)

If the participant received the requested service, what was What documentation/evidence is available to show that the participant received the
the date the participant received it?
service?
MM/DD/YYYY

Enter "Not Received" if the participant never received the service.

Enter "Not Received" if the participant never received the
service.
If the participant received the requested service, in full (i.e., as initially requested) the
organization may enter NA in all remaining columns.

Pending OMB Approval (0938-New)

Where was the request initially documented When was the participant/participant
(progress notes, assessments, PAC minutes, representative notified of the decision to
on-call, etc.)?
approve or deny the request.
Enter "Not Resolved" if the request was
never processed/resolved.

Was the request approved or denied?
Enter "Not Resolved" if the request was
never processed/decided.

If the request was approved but the service
was not provided, explain why.
Enter NA if the request was never processed
or the request was denied.

Enter "Not Notified" if the request was
decided/processed but the participant was
never notified.
MM/DD/YYYY

Pending OMB Approval (0938-New)

Were there any negative participant outcomes?

If yes, describe the negative outcomes.

(Yes/No)

Enter NA if the participant did not experience negative outcomes.

Pending OMB Approval (0938-New)

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 service
delivery request, please enter the information in this column.

Pending OMB Approval (0938-New)