CMS-10717 Root Cause Analysis

Root Cause Analysis
For CMS use:
Program Area
To be completed by CMS: Enter program area
Date Issue Identified
To be completed by CMS: Select date
Brief Description of Issue
To be completed by CMS: Enter brief description of issue
Condition
To be completed by CMS: Enter condition
Related to Pre-Audit Issue Summary (PAIS)
To be completed by CMS: Select Yes/No
PAIS Number
To be completed by CMS: If above is Yes, enter number. If No, enter NA.

For sponsoring organization use:
Description of Issue
To be completed by sponsoring organization: Provide detailed description of the overall issue
(i.e., beyond the case level); explain what happened.
Root Cause
To be completed by sponsoring organization: Provide the root cause that attributed to the
overall issue (i.e., beyond the case level); explain why the issue occurred.

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Methodology Used to Determine Root Cause *
To be completed by sponsoring organization: Provide approach used to establish why the issue
occurred; explain how the root cause was determined.
Methodology to Determine Full Scope of Impact
To be completed by sponsoring organization: Provide approach to identify those affected by the
issue; explain how impacted parties (e.g., enrollees, employees, FDRs) will be identified.
Include number impacted, if known.

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.

*

To the extent that the methodology changes after completion of the full impact analysis, the
sponsoring organization would update this section and re-upload this template to HPMS at the time the
full impact analysis is uploaded.

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