CMS-10210 Validation Review for Reconsideration Request

CMS Hospital Inpatient Quality Reporting Program Validation Review for Reconsideration Request
If the Centers for Medicare & Medicaid Services (CMS) determines that a hospital did not meet any of the Hospital Inpatient Quality Reporting
(IQR) Program requirements due to a confidence interval validation score of less than 75 percent and the hospital would like to request a
reconsideration, the hospital must complete and submit this form. Additionally, hospitals that need to submit a revised medical record may still do
so, but any hospitals that would just be resubmitting a copy that was previously sent to the Clinical Data Abstraction Center (CDAC) Contractor are
not required to do so.
Note: CMS limits the scope of data validation reconsideration reviews to information already submitted by the hospital during the initial validation
process, and we will not abstract medical records that were not submitted to the CMS contractor during the initial validation process. We will expand
the scope of our review only if we find during the review that the hospital correctly and timely submitted the requested medical records.
This form and the entire medical record (if applicable) must be received by the Validation Support Contractor within 30 days following the date of
receipt of the Hospital IQR Program Annual Payment Update (APU) Notification Letter. Medical records and/or additional documentation to
support a hospital’s rationale may be sent to the “Validation Support Contractor” group via the CMS Managed File Transfer (MFT) application:
https://qnetmft.cms.gov/. Contact validation@telligen.com for assistance.
Following the receipt of the request form/medical records, 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.
Fields marked with (*) indicates required field

*Facility Information:
*CMS Certification Number (CCN):

*Hospital Name:

*Designated Personnel Contact Information:
*Name and Title: _______________________________________________________________
*Email Address: ________________________________________________________________
*Telephone Number: ______-______-_______ Ext. __________
*Validation Review for Reconsideration Request Form:
Fields marked with (†) can be found on the Case Detail Report.
If you need to request reconsideration for more elements, or if additional space is needed to describe the rationale, you may attach another document to accompany this form.

January 2025

Patient
ID*†

January 2025

Abstraction
Control #*†

Discharge
Quarter*†

Discharge
Date*†

Data
Element
Name*†

Rationale*: Please provide written justification in the space below for each appealed data

element classified as a mismatch. Mismatched data elements that affect a hospital’s validation
score would be subject to reconsiderations. Supplemental information that was not located in the
original medical record sent to the CMS Clinical Data Abstraction Center (CDAC) cannot be
accepted.

Patient
ID*†

January 2025

Abstraction
Control #*†

Discharge
Quarter*†

Discharge
Date*†

Data
Element
Name*†

Rationale*: Please provide written justification in the space below for each appealed data

element classified as a mismatch. Mismatched data elements that affect a hospital’s validation
score would be subject to reconsiderations. Supplemental information that was not located in the
original medical record sent to the CMS Clinical Data Abstraction Center (CDAC) cannot be
accepted.

Patient
ID*†

Abstraction
Control #*†

Discharge
Quarter*†

Discharge
Date*†

Data
Element
Name*†

Rationale*: Please provide written justification in the space below for each appealed data

element classified as a mismatch. Mismatched data elements that affect a hospital’s validation
score would be subject to reconsiderations. Supplemental information that was not located in the
original medical record sent to the CMS Clinical Data Abstraction Center (CDAC) cannot be
accepted.

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 XX/XX/XXXX). 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 Validation Support Contractor at validation@telligen.com.

January 2025