CMS-10630 Clinical Appropriateness and Care Planning Impact Analys

Audit Review Period:
Issue of non-compliance:

Provision of services

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 any limitations were applied to Medicare, Medicaid, or PACE benefits.
• 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)

During the audit review period, were any limitations applied to the amount, duration, or scope of
Medicare or Medicaid benefits that were:
• requested by the participant/participant representative ;
• determined necessary by the IDT or an IDT member;
• Approved by IDT;
• Included in the participant's care plan; or
• ordered by a PCP or physician extender?

Date of initial
request/determination/approval.
MM/DD/YYYY
Each limitation must be described on a
new line.

(Yes/No)
These limitation may include but are not limited to, Home Care, DME, Medications, Dental Services,
Hearing Services, Nursing Facility stays/placement, ER use, etc.
If No, the PO may enter NA in all remaining fields.

Pending OMB Approval (0938-New)

Was the service:
• requested by the participant/participant representative ;
• determined necessary by the IDT or an IDT member;
• Approved by IDT;
• Included in the participant's care plan;
• ordered by a PCP or physician extender; or
• ordered or recommended by a contracted or non-contracted provider?

Describe the service or item to which the limitation was
applied.

If the service was requested or determined necessary by the IDT, what
was the request or determination?

(Example: Glasses, home care, hearing aids, etc.)

(Example: participant requested overnight home care)

If another scenario applies, please enter a brief description.

Pending OMB Approval (0938-New)

Describe the limitation that was applied.

Describe why the limitation was applied.

(Examples: Glasses only provided once a year, or home care is not provided
overnight, etc.)

Pending OMB Approval (0938-New)

Who applied the limitation (or determined that
the limitation should apply)?

What date was the determination to limit the
service rendered.
MM/DD/YYYY

Did the participant ever receive the service
without limitation (per the original request or
determination)?

If yes, date the participant received the
unlimited service (per the original request or
determination).

(Yes/No)

MM/DD/YYYY
Enter NA if there was a limitation applied.

Pending OMB Approval (0938-New)

Were there any negative participant
outcomes?
(Yes/No)

If yes, describe the negative outcomes.

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

Enter NA if the participant did not experience negative outcomes.

If there are any mitigating factors that you would like CMS to consider related to a
specific participant, please enter the information in this column.

Pending OMB Approval (0938-New)