CMS-10717 Pre Audit Issue Summary

Instructions: Provide a list of all disclosed issues of noncompliance that are relevant to the program areas and scope of universe being audited. A disclosed issue is one that has been reported to CMS prior to the date of the audit engagement letter. Issues identified by CMS through on-going monitoring or other account management/oversight activities during the plan year are not considered disclosed. This template is due within 5 business days after the
receipt of the engagement letter. Please upload this completed spreadsheet to the HPMS Audit Module as follows: Data Upload tab, Level Association "Audit", File Type "Supplemental File", document name "Pre-audit Issue Summary".
Issue
number

Program Area
Impacted

Description of the issue
(explain what happened)

Root cause analysis of the issue
(explain why it happened)

# of enrollees
impacted

Date issue identified
Submit in CCYY/MM/DD
format (e.g., 2020/01/01)

Date issue disclosed to CMS
Submit in CCYY/MM/DD
format (e.g., 2020/01/01)

To whom the issue was
disclosed
(first and last name)

Was the issue fully
remediated in the
Sponsoring
organization's system
and for enrollees?
Y/N

Description of system/operational
remediation

Date
system/operational
remediation initiated
Submit in
CCYY/MM/DD
format
(e.g., 2020/01/01)

Date
system/operational
remediation completed
Submit in
CCYY/MM/DD
format
(e.g., 2020/01/01)

Description of remediation for negatively
impacted enrollees

Date enrollee
outreach and
remediation initiated
Submit in
CCYY/MM/DD
format (e.g.,
2020/01/01)

Date enrollee outreach
and remediation
completed
Submit in
CCYY/MM/DD format
(e.g., 2020/01/01)

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