CMS-10191 ODAG GRV 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

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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

Enrollee ID

Contract ID

Plan ID

Date grievance/
complaint was
received
CCYY/MM/DD

Time grievance/
complaint was received
(expedited only)
(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; Organization 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,
Date oral notification
Time oral notification
Description of the
did the plan notify the
Date written notification of Time written notification
resolution (ensure text
member of the reason(s) provided to enrollee (if no provided to enrollee (if no
resolution provided to
of resolution provided to
oral notification, please
oral notification, please
field is formatted so text
for the delay and of their
enrollee
enrollee
indicate N/A)
indicate N/A)
wraps and the entire field
right to file an expedited
CCYY/MM/DD
(HHMMSS- Military time)
CCYY/MM/DD
(HHMMSS- Military time)
is readable)
grievance?
(Y/N/NA)

If appeal or organization determination
request was included with the grievance,
date of member outreach
CCYY/MM/DD

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
Date of appeal disposition
(request approved/denied on reconsideration)
CCYY/MM/DD

v. 12-2019

Time of appeal
disposition
(HHMMSSMilitary time)

v. 12-2019