CMS-10250. OQR_Rec CMS-10250. OQR_Reconsideration Form

CMS Quality Reporting Program APU Reconsideration Request Form

When the Centers for Medicare & Medicaid Services (CMS) determines that a facility did not meet the Quality Reporting Program requirement(s) for the Annual Payment Update (APU), the facility may submit a request for reconsideration to CMS by the deadline identified on the APU Notification Letter.

Once this form has been completed, please submit via the Hospital Quality Reporting Secure Portal to QRFormsSubmission@hsag.com, via secure fax to 877-789-4443, or email QRFormsSubmission@hsag.com.

Following the receipt of the request form, an email acknowledgement will be sent confirming the form has been received. Once a determination has been made, CMS will provide the formal decision regarding the reconsideration request.

*Indicates required field

*Facility Information:

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*Program Requesting Reconsideration: Inpatient Psych Outpatient Ambulatory Surgical Center (ASC)

*Date of Request (MM/DD/YYYY): / /

*CMS Certification Number (CCN) (Not required for ASC):

*National Provider Identification (NPI) (Required for ASC only):

*Facility Name:

*CEO Contact Information (Required for Inpatient and Psych) or Designated Contact Information (Required for Outpatient and ASC):

Please ensure within your organization that U.S. Mail and deliveries from overnight services directed to this address will reach the necessary party.

*Name and Title:

*Email Address:

*Telephone Number: Ext.

*Mailing Address (must include physical address; P.O. Box addresses are not valid):

*City:

*State: *ZIP Code: -

*Security Official Contact Information (Not required for ASC):

*Name and Title:

*Email Address:

*Telephone Number: Ext.

*Mailing Address (must include physical street address; P.O. Box addresses are not valid):

*City:

*State: *ZIP Code: -

*Reconsideration Request Information:

*CMS-Identified Reason Facility Did Not Meet the APU Requirements: These details were provided in the formal CMS APU Notification Letter that was sent to your CEO/Designee.

*Reason for Reconsideration Request: Please state your facility’s reason for requesting reconsideration. This must identify the specific reason(s) for believing your facility did meet the Quality Reporting Program requirements and should receive the full APU. Please Note: A

facility must submit all documentation and evidence that supports its request for reconsideration at the time that it submits its request. This includes copies of any communications, such as emails that the facility believes demonstrate its compliance with the program requirements.

Additional Comments:

Validation Review for Reconsideration Request Information:

Was one of your reasons for not meeting the annual requirement(s) related to Validation?

If Yes, PLEASE NOTE: Requests related to validation element mismatches for the clinical process measures may require additional facility actions.

Electronic Clinical Quality Measure (eCQM) Validation:

No further actions are required.

Chart-Abstracted Validation:

In addition to filing the Reconsideration Request Form as outlined above, hospitals must:

• Complete the Validation Review for Reconsideration Request Form (available on the QualityNet website), including written justification for each data element classified during the validation process as a mismatch that you wish to appeal.

• Send a copy of the entire medical record (as previously sent to the Clinical Data Abstraction Center [CDAC] Contractor) for the appealed element(s), along with the completed Validation Review for Reconsideration Request Form, to the Validation Support Contractor via the Hospital Quality Reporting Secure Portal, Managed File Transfer (MFT) “Validation Support Contractor” group. If unable to submit via MFT, you may mail to:

Telligen

Attn: Validation Support Contractor 1776 West Lakes Parkway

West Des Moines, IA 50266

Please Note: Medical records may contain Protected Health Information (PHI) and cannot be sent via email.

Medical records must be received by the deadline identified on the APU Notification Letter. CMS will review the data elements that were labeled as mismatched, as well as the written justifications provided by the facility, and make a decision on the validation reconsideration request.

SIGNATURE

*CEO/Designated Personnel Signature Date / /

PRA Disclosure Statement

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 0938-1022 (Expires 01-31-

2026). The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. 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, MD 21244-1850. ****CMS

Disclosure**** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Inpatient Value, Incentives, and Quality Reporting Outreach and Education Support Contractor at (844) 472-4477.

January 2022

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