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:
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Contract Numbers:
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Name and Title of Person Completing Questionnaire:
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Date Completed:
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1. Has your organization experienced any seamless enrollments, Plan Benefit Package
(PBP) mergers, acquisitions, or plan consolidations within the 12 months preceding the
date of the engagement letter? If so, please describe the circumstance.
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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.
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3. Describe your organization’s internal system utilized for tracking Health Risk
Assessments (HRAs), Individualized Care Plans (ICPs), and Interdisciplinary Care
Team (ICT) decisions and activities.
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OMB Approval 0938-1395 (Expires 05/31/2024)

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.
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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?
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6. Describe the process for tracking Model of Care training for ICT-implicated staff and
First Tier, Downstream, and Related Entities (FDRs).
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7. Describe the outreach policy pertaining to HRA administration and ICP
development. Describe the process for enrollees that cannot or do not want to be
contacted.
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8. Please identify FDRs that you contract with that conduct SNP related care
coordination activities, such as administering HRAs or outreach.
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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
0938-1395 (Expires 05/31/2024). This is a mandatory information collection. 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. ****CMS Disclosure**** 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 [email protected].

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OMB Approval 0938-1395 (Expires 05/31/2024)