CMS-10191 CDAG GRV Impact Analysis

Date 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 Summary?
(Completed By The CMS Team
Lead)
(Y/N)

Pre-Audit Issue Summary Number
(Completed By The CMS Team
Lead)
(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 Members
Impacted

Action 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

Enrollee ID

Contract ID

Plan ID

Effective Date of
Enrollment
CCYY/MM/DD

Is beneficiary
currently
enrolled?
(Y/N)

Date grievance/ complaint was received
CCYY/MM/DD

Time grievance/
complaint was
received
(HHMMSS- Military
time)

How was the grievance/
complaint received
(Oral or Written)

Category of the grievance/complaint; at a minimum,
categories must include each of the following:
Enrollment/Disenrollment; Plan Benefits; Coverage
Determinations, Appeals Process; Marketing;
Confidentiality/ Privacy; Quality of Care, Expedited cases;
Fraud & Abuse; Other

Description of the grievance

Was the grievance/
complaint processed
under the expedited
timeframe?
(Y/N)

Was a
timeframe
extension
taken?
(Y/N)

If an extension was taken, did the
plan notify the member of the
reason(s) for the delay and of their
right to file an expedited grievance?
(Y/N/NA)

Date oral notification
provided to enrollee
(if no oral notification,
please indicate N/A)
CCYY/MM/DD

Time oral notification
provided to enrollee
(if no oral notification, please
indicate N/A)
(HHMMSS- Military time)

Date written
notification of
resolution provided to
enrollee
CCYY/MM/DD

Time written
notification of
resolution provided to
enrollee
(HHMMSS- Military
time)

Brief summary of issue resolution
(e.g. new grievance letter and reason,
prescriber contact and outcome,
coverage determination initiated)

If appeal or coverage
determination request was
included with the
grievance, date of member
outreach.

If sponsor offered member the
opportunity to file an appeal, did the
member accept
(Y/N/NA= Sponsor did not offer an
appeal)

Date of appeal
(N/A Sponsor did not offer the
opportunity to file an appeal or member
declined opportunity)
CCYY/MM/DD

Description of the appeal disposition
(request approved/denied on
redetermination)

Date of appeal disposition
CCYY/MM/DD

v. 12-2019