CMS-10191 CDAG CDM Impact Analysis

Date Issue Identified
CCYY/MM/DD
(Completed By The
CMS Team Lead)

Brief Description Of Issue
(Completed By The CMS Team Lead)

Condition Language
(Completed By The CMS Team Lead)

Related to Pre-Audit Issue
Pre-Audit Issue Summary
Number
Summary?
(Completed By The CMS Team (Completed By The CMS
Lead)
Team Lead)
(Y/N)
(If applicable)

Detailed Description of the Issue
(Explain what happened)
(Remaining fields to be completed by Sponsor)

Root Cause Analysis for the Issue
(Explain why it happened)

Methodology - Describe the
process that was undertaken to
determine the # of members
impacted

# of Drugs Affected

List Of Drugs Affected

# of Members
Impacted

Actions Taken to Resolve System/Operational
Issues

Date System/Operational
Remediation Initiated
CCYY/MM/DD

Date System/Operational
Remediation Completed
CCYY/MM/DD

Actions Taken to Resolve Negatively Impacted Beneficiaries
Including Outreach Description and Status

Date Beneficiary Outreach and
Remediation Initiated
CCYY/MM/DD

Date Beneficiary Outreach and
Remediation Completed
CCYY/MM/DD

v. 12-2019

GPI 14 or GCN

NDC
(11 digits; no hyphens or spaces)

RxCUI

Drug Name

Number of Impacted
Members

Protected Class
(Y/N)

v. 12-2019

Enrollee ID

Contract ID

Plan ID

Effective Date of
Enrollment
CCYY/MM/DD

Is beneficiary
currently
enrolled?
(Y/N)

GPI 14 or GCN

NDC
(11 digits; no hyphens or
spaces)

Drug Name

Request type CD or RD

Expedited CD or
RD?
(Y/N)

Date request was
received
(CCYY/MM/DD)

Time request was
Was the request
received
(HHMMSS- Military approved or denied?
time)

Date request was
approved/denied
(CCYY/MM/DD)

Date of written
notification
(CCYY/MM/DD)

If decision or
Number of hours
notification was
Time of written
Number of hours
decision/effectuation
Dates of adjudicated
notification untimely
notification
untimely, was the
claims after decision date
untimely
(N/A if not
(HHMMSS- Military case forwarded to the
(N/A if not
(CCYY/MM/DD)
time)
IRE?
applicable)
applicable)
(Y/N)

Did beneficiary ever receive the
originally requested medication as
evidenced by a paid claim?

If yes in column V, indicate Date issue was resolved
Brief summary of issue resolution
number of elapsed days from
(e.g. new notification letter and reason, prescriber contact
or remediated
and outcome, beneficiary received medication)
date of receipt of request.
(CCYY/MM/DD)

If approval was not granted, provide brief explanation
(ex: outreach to MD showed member is on similar
medication and no longer needs the medication)

Request type
(e.g., tiering exception; non-formulary exception; Part B vs.
Part D; DMR; Other)

(Y/N)

v. 12-2019