CMS-10191 SNP MOC ICP ICT Impact

Date Identified
(CCYY/MM/DD)
(Completed by
Team Lead)

Brief Description Of Issue
(Completed by Team Lead)

Condition Language
(Completed by Team Lead)

Related to Pre-Audit Issue Summary?
(Y/N) (Completed by Team Lead)

Pre-Audit Issue Summary
Number (Completed by
Team Lead)
(If Applicable)

Detailed Description of the Issue
(Explain what happened)
(Remaining fields to be
Completed By The 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
Remediation Initiated
(CCYY/MM/DD)

Date Beneficiary Outreach and
Remediation Completed
(CCYY/MM/DD)

v. 12-2019

Enrollee ID

Beneficiary Name

Contract ID

Plan ID

Plan Type

Effective Date of
Enrollment
(CCYY/MM/DD)

Was an
HRA
Conducted?
(Y/N)

If an HRA Was
Conducted, Were
Needs Identified?
(Y/N)

If an HRA Was Conducted and
Needs Were Identified, Was an
ICP Created? (Y/N)

If an ICP Was
Created, Were the
Identified Needs
Addressed? (Y/N)

Was an ICT
Created?
(Y/N)

Were ICT
Is There Evidence That the PCP
Meetings
Was Invited to Participate on the
Conducted at
Beneficiary's ICT? Y/N
Least Annually?
(Y/N)

v. 12-2019