CMS-10191 FA Impact Analysis

Date Issue Identified
CC YY/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)

Rel ated to Pre-Audit Issue Summary?
(Y/N)
(Completed By The CMS Team Lead)

Pre-Audit Issue Summary
Number
Detailed Descri ption of the Issue
(If Applicable)
(Explain what happened)
(Completed By The CMS (Remai ning fields to be completed by Sponsor)
Team Lead)

Root Cause Anal ysis for the Issue
(Expl ain w hy it happened)

Methodology - Describe the process that w as undertaken to
determine the # of members i mpacted

# of Drugs Affected

List Of Drugs Affected

# of Members Impacted

Actions Taken to Resolve
System/Operational Issues

Date System/Operational
Remediation Initiated
CC YY/MM/DD

Date System/Operational
Remediation Completed
CC YY/MM/DD

Actions Taken to Resolve Negati vely Impacted Beneficiaries
Incl uding Outreach Description and Status

Date Beneficiary Outreach and
Remediation Initiated
CC YY/MM/DD

Date Beneficiary Outreach and
Remediation Completed
CC YY/MM/DD

v. 12-2019

GPI 14 or GCN

NDC
(11 digits; no hyphens or spaces)

RxCUI

Drug Name

Number of
Impacted Members

v. 12-2019

Cardholder ID

Medicare
Beneficiary
Identifier
(MBI)

Contract ID

Plan ID

Effective Date of
Enrollment
CCYY/MM/DD

Is beneficiary
currently enrolled?
(Y/N)

Date of Service
CCYY/MM/DD

Date of Rejected
Claim
CCYY/MM/DD

Time of Rejected
Claim
(HHMMSSMilitary time)

GPI 14 or GCN

NDC (11 digit; no
hyphens or spaces)

Drug Name & Strength

Drug Quantity

Drug Days Supply

Processing Error Code #1:
(NCPDP reject code causing
claim to reject)

Processing Error Msg #1:
Pharmacy Messaging

Pharmacy
Error
Code #2

Pharmacy Error
Msg #2

Pharmacy
Error
Code #3

Pharmacy Error
Msg #3

Number of Days
Time of
Beneficiary Went
Date of Paid Claim for Time of Paid Claim for a
Date ofSubsequent Subsequent Paid
Without
Pharmacy Pharmacy Pharmacy Pharmacy
a Related Drug Related Drug - Enter
Related Drug NDC
Medication
Pharmacy
Patient
Paid Claim - Enter Claim - Enter N/A
Related Drug GPI14
Enter N/A if never
N/A if never received
Error
Error Msg Error
Error Msg
(11 digits; no hyphens
(Target or
Service Type Residence N/Aifnever received if never received
or GCN
received
(HHMMSS- Military
Code #4
#4
Code #5
#5
or spaces)
(HHMMSSRelated) - Enter
CCYY/MM/DD
CCYY/MM/DD
time)
N/A if never
Military time)
received

Related Drug Name &
Strength

Related Drug
Quantity

Related Drug
Days Supply

Compound Code

Ingredient
Cost (($)

Dispensing
Fee ($)

Total Drug
Cost ($)

Patient Paid
Amount ($)

Pharmacy Service
Type

Patient Residence
(e.g., LTC)

v. 12-2019