CMS-10191 ODAG DIS Impact

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
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

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 Date Beneficiary Outreach and
Remediation Initiated
Remediation Completed
CCYY/MM/DD
CCYY/MM/DD

v. 12-2019

Enrollee ID

Contract
ID

Plan
ID

Cl ai m Number
(enter NA if
not avail able)

Person who
made the
request (CP,
NCP, B , B R)

Type of Request
(grievance, pre-service
OD, pre-service
reconsi derati on, NCP
clai m, DMR, NCP
reconsi derati on, DMR

Provi der Type Date the request was
(CP/ NCP/ NA) recei ved
CCYY/ MM/ DD

Ti me the request was
recei ved (HHMMSS Military ti me)

Issue Descri pti on

Is this an expedi ted or standard
request (E/S)

Date the request was dismissed
CCYY/ MM/ DD

Ti me the request was dis missed
(HHMMSS - Mili tary ti me)

Reason for Dis missal (e.g ., no
AOR, no WOL, unti mel y filing )

Date written
notificati on provi ded
to enrollee/ provi der
CCYY/ MM/ DD

Ti me written noti ficati on
provi ded to
enrollee/ provi der
(HHMMSS - Mili tary
ti me)

Appealed to IR E
(Y/ N)

Date forwarded to
IRE
CCYY/ MM/ DD

If pl an directed
care, amount of
enrollee li ability
($)

Amount enrollee
pai d i n res ponse to
recei vi ng notice of
liability ($ )

If enrollee pai d,
amount ($ )

Amount enrollee
reimbursed ($)

Date enrollee
reimbursed
CCYY/ MM/ DD

v. 12-2019