Medicare Advantage and Prescription Drug Plan CAHPS® Survey

Discrepancy Report
     

MA & PDP CAHPS
Discrepancy Report

Discrepancy Report Process

On occasion, a survey vendor may identify discrepancies from MA & PDP CAHPS Survey protocols that require corrections to procedures and/or electronic processing to realign the activity to comply with MA & PDP CAHPS Survey protocols. Survey vendors are required to notify CMS of these discrepancies immediately upon discovery. In its oversight role, the MA & PDP CAHPS Survey Project Team may also identify discrepancies that require correction.

  • To formally notify CMS of discrepancies such as these, survey vendors are required to complete and submit a Discrepancy Report within one business day of the survey vendor becoming aware of a discrepancy. The date the discrepancy was discovered must be clearly identified on the form.
  • The plan’s CMS contract number (Hxxxx, Rxxxx or Sxxxx) must be included on the form.

 

This form must be submitted using the form provided below. All required sections are indicated with an asterisk (*). The required information regarding the affected plans must be provided in Sections II and III in order to submit the MA & PDP CAHPS Survey Discrepancy Report. If any information is not known at time of report submission, enter “Pending” in any of the required fields in Section II and/or III. Any information reported as “Pending” must be provided in an updated report within 7 days of submitting the Initial Discrepancy Report.

Date Submitted: 10/19/2017


Indicate whether this report is an Initial Discrepancy Report or an Updated Discrepancy Report.

Initial Report (Must be submitted within one business day of a discrepancy)

Updated Report (Must be submitted within one week of original Discrepancy Report)

Date of original report submission: Original Report Form ID:

I. GENERAL INFORMATION

1. Survey Vendor Organization Information
* Organization Name:
* Mailing Address 1:
  Mailing Address 2:
* City: * State: * ZIP Code:


2. Survey Vendor Contact Person
* First Name, Last Name:
  Title:
* (Area Code) Telephone Number: (Area Code) Fax Number:
* Email Address:


3. Date Discrepancy Was Discovered
* Date:


II. LIST ALL PLAN NAMES AND NUMBERS IMPACTED BY THIS DISCREPANCY REPORT

* Plan Name:      * CMS Contract Number:


Plan Name CMS Contract Number
{{plan.grpPracticeName}} {{plan.grpPracticeID}}

III. DISCREPANCY INFORMATION

Please complete items 1 through 4 below in detail. If any information is unknown at time of initial report, enter “Pending.” Any information reported as “Pending” must be provided in an updated report within 7 days of submitting the initial report.
1. * Description of discrepancy and how it was discovered


2. *Affected timeframe for each plan listed (e.g., mm/dd/yyyy - mm/dd/yyyy)


3. * For each plan listed, provide:
  1. CMS Plan Number
  2. Total sampled members
  3. Number of sampled beneficiaries affected by the discrepancy


4. * Description of corrective action to be taken to address discrepancy, along with proposed timeline


5. * Additional information not provided above which will help the MA & PDP CAHPS project team understand the discrepancy


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