CaseFileCoverSheet - Track Change version

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 20263 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.



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.

Enter ‘Not Available’ if the information cannot be provided.
Enter ‘Does Not Apply”Not Applicable’ if the information
requested does not apply to the sample.

Page Number

SDR Information Requested by CMS

Enter the name of the document where the requested
information is located.



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

Enter ‘Not Available’ if the information cannot be provided.
Enter ‘Does Not Apply”Not Applicable’ if the information
requested does not apply to the sample.

Page Number

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 20263 Audit Protocol for
more detailed information regarding documentation requirements.
Enter the name of the document where the requested
information is located.
Appeals Information Requested by CMS




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).

Enter ‘Not Available’ if the information cannot be provided.
Enter ‘Does Not Apply”Not Applicable’ if the information
requested does not apply to the sample.

Page Number

Enter the name of the document where the requested
information is located.
Appeals Information Requested by CMS





Enter ‘Not Available’ if the information cannot be provided.
Enter ‘Does Not Apply”Not Applicable’ if the information
requested does not apply to the sample.

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.

Page Number

Enter the name of the document where the requested
information is located.
Appeals Information Requested by CMS




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.

Enter ‘Not Available’ if the information cannot be provided.
Enter ‘Does Not Apply”Not Applicable’ if the information
requested does not apply to the sample.

Page Number

Enter the name of the document where the requested
information is located.
Appeals Information Requested by CMS




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.

Enter ‘Not Available’ if the information cannot be provided.
Enter ‘Does Not Apply”Not Applicable’ if the information
requested does not apply to the sample.

Page Number

Grievance 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 20263 Audit Protocol for
more detailed information regarding documentation requirements.

Grievance Information Requested by CMS

Enter the name of the document where the requested
information is located.



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).

Enter ‘Not Available’ if the information cannot be provided.
Enter ‘Does Not Apply”Not Applicable’ if the information
requested does not apply to the sample.

Page Number

Grievance Information Requested by CMS

Enter the name of the document where the requested
information is located.



Documentation the PO cooperated with a QIO investigation, if
applicable.
Other

Enter ‘Not Available’ if the information cannot be provided.
Enter ‘Does Not Apply”Not Applicable’ if the information
requested does not apply to the sample.

Page Number

Personnel 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 20263 Audit Protocol for
more detailed information regarding documentation requirements.

Personnel Information Requested by CMS

Enter the name of the document where the requested
information is located.



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.

Enter ‘Not Available’ if the information cannot be provided.
Enter ‘Does Not Apply”Not Applicable’ if the information
requested does not apply to the sample.

Page Number

Personnel Information Requested by CMS

Enter the name of the document where the requested
information is located.



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

Enter ‘Not Available’ if the information cannot be provided.
Enter ‘Does Not Apply”Not Applicable’ if the information
requested does not apply to the sample.

Page Number