CMS-10191 SNP MOC Impact

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

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

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

Element Affected Enrollment, HRA/ICP, MOC

Effective Date of
Enrollment
(CCYY/MM/DD)

Initial HRA Deadline Effective enrollment
date + 90 days
(CCYY/MM/DD)

Initial HRA Date
(CCYY/MM/DD)

Initial HRA
# of Days Late

Audit Period
Annual HRA Date
(CCYY/MM/DD)

Prior HRA Date
(CCYY/MM/DD)

Annual HRA
# of Days Late

Initial ICP Date
(CCYY/MM/DD)

Date of Most Recent
ICP
(CCYY/MM/DD)

Basis of Most Recent ICP

Date of Prior ICP
Update
(CCYY/MM/DD)

Basis of
Prior ICP

Other #1
(if applicable)

Other #2
(if applicable)

Other #3
(if applicable)

Sponsor's Clarifying Comments
(if applicable)

v. 12-2019