CMS-10630 Clinical Appropriateness and Care Planning Impact Analys

---

Overview

Instructions
Root Cause Detail
Root Cause Summary
Participant Impact

---

Sheet 1: Instructions

Audit Review Period:
Issue of non-compliance:	Access to emergency services
Scope:	• The scope of this Impact Analysis is limited to 50% of the participants enrolled during the audit review period who were not included in the provision of services sample selection. • The auditor will select the participants to be reviewed and enter their identifying information on the Participant Impact tab.
Instructions:	• Review only the participant medical records selected by the auditor. The selected participants are identified in the Participant Impact tab. • Read each question carefully before responding. • Respond to the questions in the Participant Impact tab. • The review timeframe is the audit review period stated above. Errors noted prior to the audit review period should not be included. • After completing the Impact Analysis, if any changes need to be made to the Root Cause Analysis, please update the RCA tab.
Impact Analysis Due Date:

---

Sheet 2: Root Cause Detail

Brief Description Of Issue (Completed By The CMS Audit Lead)

Detailed Description of the Issue (Explain what happened)

---

Sheet 3: Root Cause Summary

Date Identified (MM/DD/YY) (Completed By The CMS Audit Lead)

Brief Description Of Issue (Completed By The CMS Audit Lead)

Condition Language (Completed By The CMS Audit Lead)

Root Cause Analysis for the Issue (Explain why it happened)

Methodology - Describe the process that was undertaken to determine the # of individuals (e.g. participants) impacted

# of Individuals Impacted

Action Taken to Resolve System/ Operational Issues

Date System/ Operational Remediation Initiated (MM/DD/YY)

Date System/ Operational Remediation Completed (MM/DD/YY)

Actions Taken to Resolve Negatively Impacted Individuals Including Outreach Description and Status

Date Individual Outreach and Remediation Initiated (MM/DD/YY)

Date Individual Outreach and Remediation Completed (MM/DD/YY)

---

Sheet 4: Participant Impact

Participant First Name

Participant Last Name

Medicare Beneficiary Identifier

Participant ID

Date of Enrollment MM/DD/YYYY

Date of Disenrollment MM/DD/YYYY Enter NA if the participant is still enrolled.

Reason for Disenrollment Enter NA if the participant is still enrolled.

During the audit review period, did the participant utilize emergency services or request to utilize emergency services (this includes requests from caregivers)? (Yes/No) If the response to column H is NO, enter NA in columns I-AA.

Did the participant contact the PO before going to the ER? (Yes/No)

If the participant contacted the PO before going to the ER please enter the date and time of the initial contact. MM/DD/YYYY, HH:MM AM/PM Enter NA if the participant did not contact the PO before utilizing emergency services.

Please briefly describe the concerns and/or symptoms reported by the participant and/or caregiver. Enter NA if the participant did not contact the PO before utilizing emergency services.

Did staff or contractors from the PO assess the participant in response to the participant/caregiver's initial contact? (Yes/No) Enter NA if the participant did not contact the PO before utilizing emergency services.

Who conducted the assessment of the participant (PCP, on-call nurse, etc.). Enter NA if the participant did not contact the PO before utilizing emergency services.

Date of assessment. MM/DD/YYYY Enter NA if the participant did not contact the PO before utilizing emergency services.

Time of assessment. HH:MM AM/PM Enter NA if the participant did not contact the PO before utilizing emergency services.

Was the assessment completed prior to the participant utilizing the ER? (Yes/No) Enter NA if the participant did not utilize the ER or if the participant/caregiver did not contact the PO before utilizing emergency services.

Did staff or contractors from the PO: • Instruct the participant and/or caregiver that prior authorization was needed before going to the ER or calling 911; or • Instruct the participant and/or caregiver that approval was needed before going to the ER or calling 911; or • Instruct the participant and/or caregiver not to go to the ER or call 911? (Yes/No) Enter NA if the participant did not contact the PO before utilizing emergency services.

Date/ Time the participant went to the ER. MM/DD/YYYY, HH:MM Enter NA if the participant did not utilize emergency services.

Did emergency room records indicate that the participant was experiencing an emergent situation? (Yes/No) Enter NA if the participant did not utilize emergency services. This question applies to all ER visits regardless of whether the participant/caregiver contacted the PO.

If emergency room records indicated that the participant experienced an emergent situation, please describe the situation. Enter NA if the participant did not utilize emergency services. This question applies to all ER visits regardless of whether the participant/caregiver contacted the PO.

If the participant was evaluated/treated in an ER, what was the final ER diagnosis. This question applies to all ER visits regardless of whether the participant/caregiver contacted the PO. Enter NA if the participant did not utilize emergency services.

Was the participant admitted to the hospital or held for observation? (Yes/No) Enter NA if the participant did not utilize emergency services. This question applies to all ER visits regardless of whether the participant/caregiver contacted the PO.

Was the participant held responsible for any of the cost of the ER visit? (Yes/No) Enter NA if the participant did not utilize emergency services. This question applies to all ER visits regardless of whether the participant/caregiver contacted the PO.

If yes, how much? This question applies to all ER visits regardless of whether the participant/caregiver contacted the PO. Enter NA if the PO covered 100% of the cost of the ER visit or if the participant did not utilize emergency services..

Did the participant experience any negative outcomes after being instructed: • That prior authorization was needed before going to the ER or calling 911; or • That approval was needed before going to the ER or calling 911; or • Not to go to the ER or call 911? (Yes/No) Enter NA if none of the above are applicable.

If yes, describe the negative outcomes. Enter NA if the participant did not experience any negative outcomes.

Optional: Please note, you do not have to complete this column. If there are any mitigating factors that you would like CMS to consider related to a specific participant, please enter the information in this column.