CMS-10630 Clinical Appropriateness and Care Planning Impact Analys

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Overview

Instructions
Root Cause Detail
Root Cause Summary
Participant Impact

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Sheet 1: Instructions

Audit Review Period:
Issue of non-compliance:	Restriction of Services
Scope:	• The scope of this Impact Analysis is no more than 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. • Review the selected medical records to determine if any limitations were applied to Medicare or Medicaid benefits. • Respond to the questions in the Participant Impact tab. • The review timeframe is the audit review period. Errors noted before or after 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:

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Sheet 2: Root Cause Detail

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

Detailed Description of the Issue (Explain what happened)

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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)

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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.

During the audit review period, were any limitations applied to the amount, duration, or scope of Medicare or Medicaid benefits that were: • determined necessary by the IDT or an IDT member; • approved by IDT; • included in the participant's care plan; or • ordered by a PCP? (Yes/No) These limitations may include but are not limited to, Home Care, DME, Medications, Dental Services, Hearing Services, Nursing Facility stays/placement, ER use, etc. If No, the PO may enter NA in columns H through S.

Date the service was: • determined necessary by the IDT or an IDT member; • approved by IDT; • included in the participant's care plan; or • ordered by a PCP. MM/DD/YYYY Each limitation must be described on a new line.

Was the service: • determined necessary by the IDT or an IDT member; • approved by IDT; • included in the participant's care plan; or • ordered by a PCP If another scenario applies, please enter a brief description.

Describe the service that was: • determined necessary by the IDT or an IDT member; • approved by IDT; • included in the participant's care plan; or • ordered by a PCP? (Example: Glasses, home care, hearing aids, etc.)

Describe the limitation that was applied. (Examples: Glasses only provided once a year, or home care is not provided overnight, etc.)

Describe why the limitation was applied.

Who applied the limitation (or determined that the limitation should apply)? (Example: IDT, PCP, Center Manager, Executive Director, PACE Governing Body, etc.)

What date was the determination to limit the service rendered. MM/DD/YYYY

Did the participant ever receive the service without limitation (per the original request or determination)? (Yes/No)

If yes, date the participant received the service without limitations (as determined necessary, approved, care planned or ordered). MM/DD/YYYY Enter NA if there was a limitation applied.

Were there any negative participant outcomes? (Yes/No)

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