CMS-10630 Service Delivery Request Impact Analysis Template

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

Scope:

Auditors:
Select All that Apply

Issue
Oral and/or written service delivery request denial rationale
Oral and/or written service delivery request denial appeal notification
Service delivery request review by IDT members

Oral and/or written service delivery request denial notification did not include the specific reasons for the denial in understandable language:
• All service delivery request denials during the audit review period. Please include denied service delivery requests only.
Oral and/or written service delivery request denial notification did not include appeal information:
• All service delivery request denials during the audit review period. Please include denied service delivery requests only.
The service delivery request was not reviewed by the complete IDT:
• All service delivery requests processed 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.
Oral and/or written service delivery request denial notification did not include the specific reasons for the denial in understandable language:
• Review each service delivery request denial to determine if oral and written notification of the denial included the specific reason for the denial in understandable language and
respond to the questions in the participant impact tab.
Oral and/or written service delivery request denial notification did not include appeal information:
• Review each service delivery request denial to determine if oral and written notification of the denial included appeal rights and respond to the questions in the participant impact
tab.
The service delivery request was not reviewed by the complete IDT:
• Review each service delivery request documentation to determine if all 11 IDT members were involved in the review of the request 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

Date Request Received by IDT
MM/DD/YYYY

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: Oral and/or written service delivery request denial rationale
Is there documentation or evidence that the participant
received oral notification of the denial?
(Yes/No)

Did documentation of the oral notification include the Is there documentation or evidence that the Did documentation of the written notification include
specific reason for the denial in a clear and
participant received written notification of the specific reason for the denial in a clear and
understandable manner?
the denial?
understandable manner?

(Yes/No)
If the auditor did not select Oral and/or written service
delivery request denial rationale on the instructions tab the PO If the participant did not receive oral notification
may enter NA in fields H-K.
please respond - NA

(Yes/No)

(Yes/No)
If the participant did not receive written notification
please respond - NA

Pending OMB Approval (0938-New)

This information is to be completed if the Impact Analysis is being requested for: Oral and/or written service delivery request denial appeal notification
Is there documentation or evidence that the Did documentation of the oral notification include
participant received oral notification of the the participant's right to appeal the denial?
denial?
(Yes/No)
(Yes/No)
If the participant did not receive oral notification
please respond - NA
If the auditor did not select Oral and/or
written service delivery request denial
appeal notification on the instructions tab
the PO may enter NA in fields L-O.

Is there documentation or evidence that the Did documentation of the written notification
participant received written notification of include the participant's right to appeal the denial
the denial?
and information describing both the standard and
expedited appeals processes?
(Yes/No)
(Yes/No)
If the participant did not receive written
notification please respond - NA

Pending OMB Approval (0938-New)

This information is to be completed if the Impact Analysis is being requested for: Service delivery request review by IDT members
Is there documentation that, at some point during the processing of the service delivery request, the request was reviewed by all
11 disciplines of the IDT?

Which IDT members were NOT involved in
the review of the service delivery request?

(Yes/No)

Enter NA if the service delivery request was
reviewed by all 11 IDT disciplines.

In order to answer Yes, the organization must have documentation or evidence that all 11 disciplines reviewed the request
between the request being made (participant indicating a need) and the decision being rendered (approving or denying the
request).

Was the service delivery request approved
or denied?

If the auditor did not select Service delivery request review by IDT members on the instructions tab the PO may enter NA in fields
P-U.

Pending OMB Approval (0938-New)

For approvals, did the participant receive
the service/item?

If the participant received the item/service, What documentation or evidence is there to
what was the date received?
show the participant received the item or
service?
(Yes/No)
MM/DD/YYYY
Enter NA is the service delivery request was
Enter NA is the service delivery request was Enter NA is the service delivery request was denied.
denied.
denied.

General Information: This information is to be completed for all Impact Analyses
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)