CMS-10630 Appeals Effectuation

---

Overview

Instructions
Detailed Sample Information
Root Cause Analysis
Participant Impact

---

Sheet 1: Instructions

Audit Review Period:
Issue(s) of non-compliance:	Auditors: Select All that Apply	Issue
		Provision of services to Medicaid participants during an appeal
		Provision of services following an approved appeal
Scope:	Provision of services to Medicaid participants during an appeal: • All appeals during the audit review period. Provision of services following an approved appeal: • All approved and partially denied appeals during the audit review period.
Instructions:	General: • The review timeframe is the audit review period. Errors noted prior to 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. Provision of services to Medicaid participants during an appeal: • Review each appeal to determine if the participant requested to continue the service during the appeal. • If the participant was enrolled in Medicaid, answer all of the remaining questions. If the participant was not enrolled in Medicaid, answer NA to all of the remaining questions. Provision of services following an approved appeal: • Review each approved and partially denied appeal and respond to the questions in the Participant Impact tab.
Impact 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 0938-1327. This information collection will allow CMS to conduct comprehensive reviews of PACE organizations to ensure compliance with regulatory requirements. The time required to complete this information collection is estimated at 780 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 1894 and 1934 of the Social Security Act and implementing regulations at 42 CFR § 460.190 and 460.194, which state that CMS, in conjunction with the State Administering Agency (SAA), audit PACE organizations (POs) annually for the first 3 contract years (during the trial period), and then on an ongoing basis following the trial period. Additionally, per § 460.200(a) PACE organizations are required to collect data, maintain records, and submit reports as required by CMS and the State administering agency. 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.

---

Sheet 2: Detailed Sample Information

Tracking ID Number	Brief Description Of Issue (Completed By The CMS Audit Lead)	Type of Issue Identified (Completed By The CMS Audit Lead) (Applies to condition 1P.02 Only. For all other conditions enter N/A)	Detailed Description of the Issue (Explain what happened)
		x

---

Sheet 3: Root Cause Analysis

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)

---

Sheet 4: Participant Impact

Section 1 - General Information: This information is to be completed for all Impact Analyses

Section 2 - This information is to be completed if the Impact Analysis is being requested for: Provision of services to Medicaid participants during an appeal

Section 3 - This information is to be completed if the Impact Analysis is being requested for: Provision of services following an approved appeal (enter all appeals that were approved at any level of the appeal (e.g., third party reviewer, Medicaid State Fair Hearings, IRE, etc.)

Section 4 - General Information: This information is to be completed for all Impact Analyses

Participant First Name

Participant Last Name

Medicare Beneficiary Identifier

Participant ID

Enrollment Type (Medicare only, Medicaid only, Dual Eligible, Private Pay)

Date Appeal Received MM/DD/YYYY

Description of the Appeal/ Specific Issue

Appeal Disposition Enter approved if all of the appealed services were approved as requested. Enter partially denied if the appealed services were not fully approved as requested and/or the appeal reviewer approved modified or alternative services. Enter denied if the appealed services were fully denied.

Was the participant enrolled in Medicaid? This includes participants who are Medicaid only and dual eligible. (Yes/No) If the auditor did not select Provision of services to Medicaid participants during an appeal on the instructions tab the PO may enter NA in all columns in Section 2. If the answer to this question is No enter NA in all remaining columns in Section 2.

Was the appeal related to a termination or reduction in services that were currently being furnished to the participant? (Yes/No)

Did the participant request to continue the service during the appeal process? (Yes/No) Enter NA if the appeal was not related to a termination or reduction in services that were currently being furnished to the participant.

Was the service continued during the appeal process? (Yes/No) Enter NA if the appeal was not related to a termination or reduction in services that were currently being furnished to the participant OR if the participant did not request to continue the service during the appeal.

If the participant requested to continue the service and the service was not continued, please enter the date the service was terminated. MM/DD/YYYY Enter NA if the participant did not request to continue the service.

If the service was terminated and the service was approved by the third-party reviewer, enter the date that the service resumed. MM/DD/YYYY Enter NA if the service was denied by the third-party or the service was never terminated.

If the participant requested to continue the service and the service was not continued, were there any negative participant outcomes? (Yes/No)

Did the PO provide approved services, as expeditiously as the participant's condition required, following a favorable appeal? (Yes/No) Enter NA if the appeal was fully denied. If the auditor did not select Provision of services following an approved appeal on the instructions tab, the PO may enter NA in all columns in Section 3. If the answer to this question is Yes or NA, enter NA in all remaining columns in Section 3.

Date the appeal decision was rendered by any appeal entity (e.g., third party reviewer, IRE, State fair hearings, etc.). MM/DD/YYYY

Entity that approved or partially denied the appeal. (Third Party Reviewer, IRE, State Fair Hearings, etc.)

If partially denied, what was the approved portion of the service? Enter NA if the appeal was approved in full.

If the service was approved or partially denied by either the third-party, Medicaid, or Medicare reviewer, enter the date that the approved service was provided or resumed. MM/DD/YYYY Enter "Not Provided" if the approved service was not provided or if there is no evidence the approved service was provided.

If the participant experienced negative outcomes, did they occur, in some part, as a result of a failure to provide the item or service, or to provide the item or service as expeditiously as the participant's condition required? (Yes/No) Enter NA if there were no negative outcomes

If the participant experienced any negative outcomes, please describe the negative outcomes. Enter NA if there were no 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 appeal, please enter the information in this column.