CMS-10191 ODAG PMNT 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

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

Claim Number

Contracted or noncontracted provider

Date the request
was received
CCYY/MM/DD

Diagnosis

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

Date denied
CCYY/MM/DD

Date written
notification
provided to
enrollee
CCYY/MM/DD

Date written
notification
provided to
provider
CCYY/MM/DD

Did the non-contract
If the non-contract
If the non-contract
provider bill the
provider billed the
provider billed the
enrollee, the amount ($) enrollee, the amount
enrollee?
(Y/N)
billed
($) the enrollee paid

Date enrollee paid
Amount enrollee paid
amount reimbursed to
reimbursed to
enrollee
enrollee
CCYY/MM/DD

v. 12-2019