CMS-10191 ODAG CDM Impact

Date Issue Identified
(CCYYMM/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

Claim Number

Request typeOD or Recon

Expedited OD or
Recon?
(Y/N)

Date request was
received
(CCYY/MM/DD)

Time the request was
received (expedited
only)
(HHMMSS- Military
time)

Diagnosis

Issue Description -- List type of
service
(e.g., SNF/HH/PT/OT)

If an OD/reconsideration was requested
under the expedited timeframe, did the plan
determine the request did not meet
expedited criteria and instead process the
OD/reconsideration under the standard
timeframe?
(Y/N/NA)

Was a timeframe extension
taken?
(Y/N/NA)

If an extension was taken, did
the plan notify the member of
the reason(s) for the delay and
of their right to file an expedited
grievance?
(Y/N/NA)

Was the request
approved or denied?

Date approved--plan level
(enter N/A if not
applicable)
(CCYY/MM/DD)

Time approved--plan
level (expedited only)
(HHMMSS- Military
time)

If denied, was the request
denied for lack of medical
necessity?
(Y/N/NA)

Date denied--plan
level
(CCYY/MM/DD)

Date oral notification
Time denied--plan
provided to enrollee
level (expedited
(if no oral
only)
notification, indicate
(HHMMSS- Military
N/A)
time)
(CCYY/MM/DD)

Time oral notification
provided (if no oral
notification, indicate
N/A) (expedited only)
(HHMMSS- Military
time)

Date written
notification provided
to enrollee
(CCYY/MM/DD)

Time written
notification provided
to enrollee
(expedited only)
(HHMMSS- Military
time)

Date written notification
provided to provider
(CCYY/MM/DD)

Date of receipt
of
IRE/ALJ/MAC
decision
(CCYY/MM
/DD)

Time of receipt for
IRE/ALJ/MAC
Date effectuated
decision (expedited
in plan's system
only)
(CCYY/MM/DD)
(HHMMSSMilitary time)

Time effectuated
in plan's system
(expedited only)
(HHMMSSMilitary time)

Was interest paid on
the claim?
(Y/N/NA)

Did the beneficiary
receive the
drug/service?
(Y/N)

Plan directed
care?
(Y/N)

If plan directed
care, amount of
enrollee liability ($)

Amount enrollee paid
in response to
receiving notice of
liability ($)

If enrollee paid,
amount ($)

Amount
enrollee
reimbursed ($)

Date enrollee
reimbursed
(CCYY/MM/
DD)

v. 12-2019