CMS-10913 Medicare Part C UM Root Cause Analysis

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Overview

Instructions
Root Cause Analysis

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Sheet 1: Instructions

Calendar Year Being Reviewed:
Instructions:	• Root Cause tab
	* Columns A through E - Will be completed by CMS.
	* Column F - The Medicare Advantage Organization (MAO) must identify the root cause or causes for the issue(s) summarized in Column E (Brief Description of Non-Compliance).
	* Column G - Completion of this column is optional. Enter 'Yes' if the applicable non-compliance was identified by the MAO prior to the start of the CMS audit.
	* Column H through M - Completion of these columns is optional. Only complete the columns if the MAO identified the applicable non-compliance prior to the start of the CMS audit.
Root Cause Analysis Due Date:
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 OMB 0938-New. This information collection will allow CMS to conduct a comprehensive review of Sponsoring organizations’ compliance with Medicare Part C utilization management (UM) requirements. The time required to complete this information collection is estimated at 410 hours per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is mandatory per CMS’s authority under Section 1857(d) of the Social Security Act and implementing regulations at 42 CFR § 422.503 and § 422.504, which state that CMS must oversee a Medicare Advantage (MA) organization’s continued compliance with the requirements for a MA organization. Additionally, per § 422.516(a), MA organizations are required to compile and report to CMS information related to the utilization of services, and other matters as CMS may require. If you have comments concerning the accuracy of the time estimate 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.

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Sheet 2: Root Cause Analysis

Tracking ID Number (Completed by CMS)

Date Non-Compliance Identified (MM/DD/YYYY) (Completed by CMS)

Condition Language (Completed by CMS)

Internal Coverage Criteria Policy Name, Title, or Identifier (Completed by CMS)

Brief Description of Non-Compliance (Completed by CMS)

Root Cause Analysis for the Issue (Explain why the non-compliance occurred.) (Completed by the MAO)

Was this non-compliance identified prior to the start of the CMS audit? (Yes/No)

Were any actions taken to correct the non-compliance? (Yes/No) Enter NA if the non-compliance was not identified before the start of the CMS audit.

Enter the date the corrective actions were initiated. (MM/DD/YYYY) Enter NA if the non-compliance was not identified before the start of the CMS audit.

Enter the date the corrective actions were fully implemented (i.e., the date the MAO was in compliance). (MM/DD/YYYY) Enter NA if the non-compliance was not identified before the start of the CMS audit.

Identify any actions taken to remediate negatively impacted individuals, including any outreach conducted. Enter NA if the non-compliance was not identified before the start of the CMS audit.

Enter the date remedial actions (including outreach) began. (MM/DD/YYYY) Enter NA if the non-compliance was not identified before the start of the CMS audit.

Enter the date remedial actions (including outreach) were completed. (MM/DD/YYYY) Enter 'ongoing' if actions are ongoing. Enter NA if the non-compliance was not identified before the start of the CMS audit.