Notice_of_Corrective_Action_Re-Assessment_508

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop S2-26-17
Baltimore, Maryland 21244-1850
Notice of Corrective Action Re-Assessment
Date of Notice: FULLDATE
CONTACTNAME
JOBTITLE
CENAME
ADDRESS1
ADDRESS2
CITY, ST ZIP
Re: Corrective Action Number XXXXX
Dear TITLE LASTNAME:
On (month, day, year), the Department of Health and Human Services (HHS), Division of
National Standards (DNS) within the Centers for Medicare & Medicaid Services’ (CMS),
opened a corrective action based on the violations discovered during the 2017 assessment.
As part of the corrective action process, submitted a corrective action
plan (CAP) that addresses the violations previously discovered. Our records indicate that
has completed this CAP and is ready for re-assessment for
compliance.
Please upload the following documents or transactions specific to the violations cited, for reassessment purposes:
1. Example: Two production 835 files created after (month, day, year) that contain one or
more adjusted claim payments at the claim level.
2. Example: Website URL to the updated 835 Companion Guide for .
Using the previously provided login information, please upload all requested information in this
letter to your secure portal site by (month, day, year) so that the re-assessment can be conducted.
We will conduct the re-assessment within 14 business days of receiving the requested
information, and will notify of the re-assessment results.
If you have any questions about this letter, please contact (contact name) at
[email protected], or 555-555-5555. When contacting this office, please include the
corrective action number located at the top of this letter.

Sincerely,
Madhu Annadata, Director
Division of National Standards
Office of Information Technology
cc:
Contact Name

In accordance with the Paperwork Reduction Act (1995), no persons are required to respond to a collection of information, unless it
displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information
collection is 0938-XXXX (Expires XX/XX/XXXX). The time required to complete this information collection is estimated to average
[10 hours] per response (4 forms x 60 minutes/form), including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to:
Centers for Medicare & Medicaid Services
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05
7500 Security Boulevard
Baltimore, Maryland 21244-1850
Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA
Reports Clearance Office. Any correspondence not pertaining to the information collection burden approved under the associated
OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding
where to submit your documents, please contact: Cecily Austin at [email protected] or Kevin Stewart at
[email protected] .