CMS-10630 Service Determination Request (SDR) Cover Sheet

The PACE Organization (PO) Monitoring and Audit Process in Part 460 of 42 CFR (CMS-10630)

CaseFileCoverSheet

Trial Year and Routine Audits

OMB: 0938-1327

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Case File Cover Sheets

Service Determination Request (SDR) Cover Sheet

Please identify where the following information is located for each case file, including the relevant page numbers (if applicable). If any information cannot be provided, enter ‘Not Available’. Please review the 2026 Audit Protocol for more detailed information regarding documentation requirements.

SDR Information Requested by CMS	Enter the name of the document where the requested information is located. Enter ‘Not Available’ if the information cannot be provided. Enter ‘Not Applicable’ if the information requested does not apply to the sample.	Page Number
Documentation of the initial request, including the date of the initial request.
Documentation identifying when the request was brought to the IDT (not applicable for immediate approvals).
Documentation of all reassessments conducted in response to the service determination request.
Documentation of full IDT involvement in the service determination request review (not applicable for immediate approvals).
Extensions Only: If the extension was requested by the participant, the participant’s designated representative, or the participant’s caregiver, documentation of their request for an extension.
Extensions Only: If the extension was taken because the IDT needed additional information from an individual not directly employed by the PO, documentation showing why the information was needed to make the decision.
Extensions Only: Documentation demonstrating when the IDT extended the SDR timeframe.
Extensions Only: A copy of the extension notification provided to the participant, the participant’s designated representative, or caregiver.
Documentation of oral notification.
Documentation of written notification.
Approvals/Partial Denials Only: Documentation identifying when and how the PO scheduled the delivery of the approved services.
Approvals/Partial Denials Only: Documentation the PO tracked the provision of the approved services.
Approvals/Partial Denials Only: Documentation of the provision of the approved services.
Other

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.

Appeals Cover Sheet

Please identify where the following information is located in the case file, including the relevant page numbers (if applicable). If any information cannot be provided, enter ‘Not Available’. Please review the 2026 Audit Protocol for more detailed information regarding documentation requirements.

Appeals Information Requested by CMS	Enter the name of the document where the requested information is located. Enter ‘Not Available’ if the information cannot be provided. Enter ‘Not Applicable’ if the information requested does not apply to the sample.	Page Number
Documentation of the initial appeal request (received in writing, orally, etc.), including any system notes, progress notes, logs, or other data related to the appeal request.
Documentation that the participant was given an opportunity to present evidence in-person as well as in writing.
Expedited Appeals Only: Documentation indicating why an appeal was expedited.
Expedited Appeals with Extensions Only: Documentation indicating why an expedited appeal was extended, including the participant’s request for an extension or documentation the PO justified the extension to the SAA (if applicable).
Documentation identifying the third-party reviewers and their credentials.
Documentation of written appeal notification (notification of the decision).
Approvals/Partial Denied Appeals Only: Documentation identifying when and how the PO scheduled the delivery of the approved services.
Approvals/Partial Denied Appeals Only: Documentation the PO tracked the provision of the approved services.
Approved/Partially Denied Appeals Only: Documentation of the provision of the approved services.
For Medicaid Participants that Requested to Continue Services Only: Documentation the PO continued to provide services during the appeal process.
Other
Information related to the underlying service determination request for the appeal
Documentation of the initial request, including the date of the initial request.
Documentation identifying when the request was brought to the IDT (not applicable for immediate approvals).
Documentation of all reassessments conducted in response to the service determination request.
Documentation of full IDT involvement in the service determination request review (not applicable for immediate approvals).
Extensions Only: If the extension was requested by the participant, the participant’s designated representative, or the participant’s caregiver, documentation of their request for an extension.
Extensions Only: If the extension was taken because the IDT needed additional information from an individual not directly employed by the PO, documentation showing why the information was needed to make the decision.
Extensions Only: Documentation demonstrating when the IDT extended the SDR timeframe.
Extensions Only: A copy of the extension notification provided to the participant, the participant’s designated representative, or caregiver.
Documentation of oral notification.
Documentation of written notification.
Approvals/Partial Denials Only: Documentation identifying when and how the PO scheduled the delivery of the approved services.
Approvals/Partial Denials Only: Documentation the PO tracked the provision of the approved services.
Approvals/Partial Denials Only: Documentation of the provision of the approved services.

Grievance Cover Sheet

Grievance Information Requested by CMS	Enter the name of the document where the requested information is located. Enter ‘Not Available’ if the information cannot be provided. Enter ‘Not Applicable’ if the information requested does not apply to the sample.	Page Number
Documentation of the initial complaint, including documentation detailing each issue and all supplemental information submitted by the participant and/or their representative (family member, designated representative, or caregiver).
Documentation showing the steps the PO took to resolve each issue identified in the grievance, including documentation of the PO’s investigation of all distinct issues within the grievance (when the cause of the issue was not already known).
Documentation describing the final resolution for each grievance issue.
Documentation that identifies the participant or representative’s preference for notification.
Resolution notification provided to participants/their representatives for each issue within the grievance or, if applicable, documentation participants/their representatives declined notification.
Documentation that the PO took appropriate follow-up actions (if necessary).
Documentation the PO cooperated with a QIO investigation, if applicable.
Other

Personnel Cover Sheet

Personnel Information Requested by CMS	Enter the name of the document where the requested information is located. Enter ‘Not Available’ if the information cannot be provided. Enter ‘Not Applicable’ if the information requested does not apply to the sample.	Page Number
Background Check, including the date the background check was competed
OIG Check, including the date the OIG check was competed
Documentation a risk assessment was completed, if applicable, including the date the risk assessment was competed
Documentation a medical clearance was completed, if applicable, including the date the medical clearance was competed
Documentation staff were determined to be free of active Tuberculosis, including the date the determination was made
Professional Licensure, if applicable
Driver’s License, if applicable
Documentation the individual is a Master’s-Level social worker, if applicable.
Documentation initial competencies were completed, including the date(s) initial competencies were competed
Date of first participant contact
Date of first independent participant contact
Other

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Daniel Deisroth
File Modified	0000-00-00
File Created	2025-07-17