CMS-10191 SNP MOC Training Impact

Date 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
(If Applicable)
(Completed By The CMS
Team Lead)

Detailed Descri ption of the Issue
(Explain what happened)
(Remai ning fields to be completed by Sponsor)

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

Methodology - Describe the process that w as undertaken to determi ne the #
impacted

Member Impact
Y/N

Member Impact Details
(Access to Care, Delayed Care,
etc.)

Actions Taken to Resolve
System/Operational Issues

Date System/Operational Remedi ation
Initiated
(CC YY/MM/DD)

Date System/Operational Remedi ation
Completed (CC YY/MM/DD)

Actions Taken to Resolve Issues, Includi ng Outreach Description
and Status

Date Outreach and Remediation
Initiated (CCYY/MM/DD)

Date Outreach and Remediation
Completed (CC YY/MM/DD)

v. 12-2019

Enrollee ID
(If member impact)

Beneficiary Name
(If member impact)

Contract ID

Plan ID

Plan Type

Provider/Staff/ICT
Name

MOC Training Date

Next Training
Due Date

Provider/Staff/ICT
Involvement with Member
Care/Coordination
(Describe)

MOC Processes Impacted
(HRA, ICT, and/or ICP
completion, etc.)

Sponsor's Clarifying Comments
(if applicable)

v. 12-2019