| Audit Review Period: | |
| Issue of non-compliance: | Remaining alert to information from specialists/contracted providers |
| 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. • Review the selected medical records to determine if any specialists, ER providers, or hospital providers recommended services for the participant. • 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: |
| Brief Description Of Issue (Completed By The CMS Audit Lead) |
Detailed Description of the Issue (Explain what happened) |
| 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) |
| 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, did the participant have specialist consultations, emergency room visits, or hospitalizations? (Yes/No) If NO, the PO may enter NA in columns H through X. |
Enter the type of specialist consultation. If the participant had an emergency room visit, enter "ER." If the participant had a hospitalization, enter "hospitalization" Enter NA if the participant did not have any specialist consultations, emergency room visits, or hospitalizations. |
Enter the date of each specialist consultation, emergency room visit, and hospitalization. For emergency room visits and hospitalizations, enter the discharge date. MM/DD/YYYY Enter NA if the participant did not have any specialist consultations, emergency room visits, or hospitalizations. |
Identify all services (including items and/or drugs) recommended or ordered by the specialist, emergency room provider, or hospital provider. Enter each item and service in a separate row. Enter NA if: 1) The participant did not have any specialist consultations, emergency room visits, or hospitalizations; or 2) No items or services were ordered or recommended by the specialist, emergency room provider, or hospital provider. |
Date the specialist consultation report, ER records, or hospital records were received by the PO. MM/DD/YYYY If records were not received, enter "not received." Enter NA if the participant did not have any specialist consultations, emergency room visits, or hospitalizations. |
Did the IDT remain alert to all pertinent information from the specialists/ER/Hospital, including recommendations made by these providers? Yes/No Enter NA if: 1) The participant did not have any specialist consultations, emergency room visits, or hospitalizations; or 2) No items or services were ordered or recommended by the specialist, emergency room provider, or hospital provider. |
Did the PACE PCP order the recommended service/item? (Yes/No) Enter NA if: 1) The participant did not have any specialist consultations, emergency room visits, or hospitalizations; or 2) No service/item was ordered or recommended by the specialist, emergency room provider, or hospital provider. |
Date the service/item was ordered by the PCP. MM/DD/YYYY Enter NA if: 1) The participant did not have any specialist consultations, emergency room visits, or hospitalizations; or 2) No service/item was ordered or recommended by the specialist, emergency room provider, or hospital provider; or 3) The PCP did not order the service/item. |
Date the service/item ordered by the PCP was provided to the participant. If service/item was ordered but not provided, enter "not provided." If more than one item or service was ordered, please identify the date each item was ordered. MM/DD/YYYY Enter NA if: 1) The participant did not have any specialist consultations, emergency room visits, or hospitalizations; or 2) No service/item was ordered or recommended by the specialist, emergency room provider, or hospital provider; or 3) The PCP did not order the service/item. |
If service/item was ordered by the PCP but was not provided, please explain why it was not provided. Enter NA if: 1) The participant did not have any specialist consultations, emergency room visits, or hospitalizations; or 2) No service/item was ordered or recommended by the specialist, emergency room provider, or hospital provider; or 3) The PCP did not order the service/item. |
If the PCP did not order the service/item, did the IDT document their rationale for not ordering the service/item in the participant's medical record? (Yes/No) Enter NA if: 1) The participant did not have any specialist consultations, emergency room visits, or hospitalizations; or 2) No items or services were ordered or recommended by the specialist, emergency room provider, or hospital provider; or 3) The PACE PCP ordered the service/item. |
What was the PCP's rationale for not ordering the service/item? Enter NA if: 1) The participant did not have any specialist consultations, emergency room visits, or hospitalizations; or 2) No items or services were ordered or recommended by the specialist, emergency room provider, or hospital provider; or 3) The PACE PCP ordered the service/item; or 4) The PACE PCP did not document their rationale for not ordering the service/item. |
Date the PCP documented their rationale for not ordering the service/item. MM/DD/YYYY Enter NA if: 1) The participant did not have any specialist consultations, emergency room visits, or hospitalizations; or 2) No items or services were ordered or recommended by the specialist, emergency room provider, or hospital provider; or 3) The PACE PCP ordered the service/item; or 4) The PACE PCP did not document their rationale for not ordering the service/item. |
If the PCP did not order the service/item, did the participant receive the service/item by some other means? For example, was the service/item provided at a specialist office? (Yes/No) Enter NA if: 1) The participant did not have any specialist consultations, emergency room visits, or hospitalizations; or 2) No items or services were ordered or recommended by the specialist, emergency room provider, or hospital provider; or 3) The PACE PCP ordered the service/item. |
Date the participant received the service/item (by other means) MM/DD/YYYY Enter NA if: 1) The participant did not have any specialist consultations, emergency room visits, or hospitalizations; or 2) No items or services were ordered or recommended by the specialist, emergency room provider, or hospital provider; or 3) The PACE PCP ordered the service/item; or 4) The participant did not receive the service/item by some other means. |
If the participant experienced negative outcomes, did they occur, in some part, as a result of the failure to provide or a delay in the provision of care and/or services? (Yes/No) Enter NA if: 1) The participant did not have any specialist consultations, emergency room visits, or hospitalizations; or 2) No items or services were ordered or recommended by the specialist, emergency room provider, or hospital provider; or 3) The PACE PCP ordered the services/items and they were provided as expeditiously as the participant's health required. |
If yes, describe the negative outcomes. Enter NA if: 1) The participant did not have any specialist consultations, emergency room visits, or hospitalizations; or 2) No items or services were ordered or recommended by the specialist, emergency room provider, or hospital provider; or 3) The PACE PCP ordered the services/items and they were provided as expeditiously as the participant's health required. 4) 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. |
| (Example) Jane | Smith | 1234 | 1/1/2021 | NA | Yes | ophthalmology | 2/1/2021 | glasses | 2/4/2021 | Yes | 2/5/2021 | 2/28/2021 | NA | NA | NA | NA | NA | NA | No | NA | |||
| (Example) Jane | Smith | 1234 | 1/1/2021 | NA | Yes | ophthalmology | 2/1/2021 | follow-up in one month | 2/4/2021 | No | NA | NA | NA | Yes | The PCP wanted to have the participant evaluated by a retinal specialist before ordered f/u with ophthalmology. | 2/5/2021 | NA | NA | No | NA |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |