Discrepancy Report Form

CAHPS^® Survey for Accountable Care Organizations
(ACOs) Participating in Medicare Initiatives
Discrepancy Report

Discrepancy Report Process

On occasion, a survey vendor may identify discrepancies from CAHPS for ACOs Survey protocols that require corrections to procedures and/or electronic processing to realign the activity to comply with the protocols. In its oversight role, the project team may also identify discrepancies that require correction.

To formally notify CMS of discrepancies that impact Next Generation Model ACOs, survey vendors are required to complete and submit a discrepancy report within one business day after the discrepancy has been discovered.
The discrepancy report notifies the project team of the nature, timing, cause, and extent of the discrepancy, as well as the proposed correction and timeline to correct the discrepancy.
The survey vendor must include the Next Generation Model ACO’s ID number on the form.

All required sections are indicated with an asterisk (*). The required information regarding the affected Next Generation Model ACOs must be provided in Sections II and III in order to submit the Discrepancy Report. If any information is unknown when you submit your report, enter “Pending” in any of the required fields in Section II and/or III. All pending information must be provided in an updated report within 7 days of submitting the Initial Discrepancy Report.

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

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

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

Date of initial Discrepancy Report submission *

Initial Discrepancy Report ID *

I. GENERAL INFORMATION

Survey Vendor Organization Information

1a.Organization Name * The Name of the Organization is required.

Submission Date 06/18/2021

1b. Mailing Address 1 * The Address is required.

1c. Mailing Address 2

1d. City * The City is required.

1e. State * The State is required.

1f. Zip Code * The Zip Code is required.

Survey Vendor Contact Person

2a. First Name * First Name is required.

2b. Last Name * Last Name is required.

2c. Title * Title is required.

2d. Telephone * Telephone is required.

2e. Fax Number Fax must be at least 10 digits.

2f. Email * Email is required.

Date Discrepancy Was Discovered

Date Discovered * Date Discovered is required.

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

At least one entry is required.

ACO Name * ACO Name is required.

ACO ID * ACO ID is required.

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III. DISCREPANCY INFORMATION

Please complete items 3a through 3e below in detail. If any information is unknown at time of initial report, enter "Pending." All pending information must be provided in an updated report within 7 days of submitting the initial report.

3a. Description of the discrepancy * Description of the discrepancy is required. {{2000 - model.DiscrepancyDescription.length}} characters remaining

3b. Description of how the discrepancy was identified * Description of how the discrepancy was identified is required. {{2000 - model.DiscrepancyIdentified.length}} characters remaining

3c. Affected timeframe for each ACO listed (e.g., mm/dd/yyyy - mm/dd/yyyy) * Affected timeframe is required. {{2000 - model.DiscrepancyTimeframe.length}} characters remaining

3d. For each ACO listed, provide *

At least one entry is required.

ACO ID * ACO ID is required.

Total sampled members * Total sampled members is required.

Number of sampled beneficiaries affected by the discrepancy * Number of sampled beneficiaries is required.

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3e. Description of corrective action to address the discrepancy, along with proposed timeline * Description of the Corrective Action is required. {{2000 - model.CorrectiveAction.length}} characters remaining

3f. Additional information not provided above which will help the CAHPS for ACOs project team understand the discrepancy *

Additional Info is required. {{2000 - model.AdditionalInfo.length}} characters remaining

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