CMS-10717 Pre Audit Issue Summary

Instructions: Provide a list of all disclosed issues of non-compliance that are relevant to the program areas and scope of universe being audited. A disclosed issue is one that has been reported to CMS prior to the date of the audit engagement letter. Issues identified by CMS through on-going monitoring or other account management/oversight activities during the plan year are not considered disclosed. This template is due within 5 business days after the
receipt of the engagement letter. Please upload this completed spreadsheet to the HPMS Audit Module as follows: Data Upload tab, Level Association "Audit", File Type "Supplemental File", document name "Pre-audit Issue Summary".
Issue
number

Program Area
Impacted

Description of the issue
(explain what happened)

Root cause analysis of the issue
(explain why it happened)

# of enrollees
Date issue identified
Date issue disclosed to CMS
impacted
Submit in CCYY/MM/DD Submit in CCYY/MM/DD
format (e.g., 2020/01/01)
format (e.g., 2020/01/01)

To whom the issue was
disclosed
(first and last name)

Was the issue fully
Description of system/operational
Date
Date
remediated in the
remediation
system/operational
system/operational
sponsor's system and for
remediation initiated remediation completed
enrollees?
Submit in
Submit in
Y/N
CCYY/MM/DD
CCYY/MM/DD
format
format
(e.g., 2020/01/01)
(e.g., 2020/01/01)

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 10938-NEW (Expires: TBD). The CMS control number is CMS-10717. The time required to
complete this information collection is estimated to average 701 hours per response, 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: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, 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. Please note that 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 1-800-MEDICARE. v. 05-2020

Description of remediation for negatively
impacted enrollees

Date enrollee
outreach and
remediation initiated
Submit in
CCYY/MM/DD
format (e.g.,
2020/01/01)

Date enrollee outreach
and remediation
completed
Submit in
CCYY/MM/DD format
(e.g., 2020/01/01)