CMS-10717 Special Needs Plans - Care Coordination Supplemental Que

Program Audit Data Request
Special Needs Plans - Care Coordination
Supplemental Questionnaire

This questionnaire is designed to assist CMS in understanding the unique qualities of your
organization’s SNP program operations. Please enter your responses to the questions below and
upload the completed form to HPMS within 5 business days of receiving your audit engagement
letter. Separate questionnaires may be provided for each entity/operating system showing the
CMS contracts that are applicable to each completed questionnaire (if multiple questionnaires
are completed, they must be zipped together and uploaded to HPMS as a single file).
Name of Sponsoring Organization:
Enter your response here
Contract Numbers:
Enter your response here
Name and Title of Person Completing Questionnaire:
Enter your response here
Date Completed:
Select date
1. Has your organization experienced any seamless enrollments, PBP mergers, acquisitions,
or plan consolidations within the 12 months preceding the date of the engagement letter? If
so, please describe the circumstance.
Enter your response here
2. Confirm your organization’s SNP plan type offerings (C-SNP, D-SNP or I-SNP) at time of
audit engagement letter and provide enrollment statistics for the three largest PBPs of each
SNP type offered as of the date of the audit engagement letter. If only 1 or 2 SNP types
offered, provide enrollment statistics for those SNP types.
Enter your response here
3. Describe your organization’s internal system utilized for tracking HRAs, ICPs, and ICT
decisions and activities.
Enter your response here

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Program Audit Data Request
Special Needs Plans - Care Coordination
Supplemental Questionnaire

4. Does your organization use an acuity scoring system to assess enrollee severity of
illness/intensity of service? If yes, please describe your organization’s enrollee risk
stratification levels and your process for assigning enrollees to a risk stratification level.
Enter your response here
5. Describe the processes when transition of care is documented for a new enrollee or an
enrollee who has experienced hospitalization. How do you define transition of care?
Enter your response here
6. Describe the process for tracking MOC training for ICT-implicated staff and FDRs.
Enter your response here
7. Describe the outreach policy pertaining to HRA administration and ICP
development. Describe the process for beneficiaries that cannot or do not want to be
contacted.
Enter your response here
8. Please identify FDRs that you contract with that conduct SNP related care coordination
activities, such as administering HRAs or outreach.
Enter your response here

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 0938-1000 (Expires:
TBD). 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.

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