10210 Data Validation Appeal Form

Hospital to complete the Part One form when the overall reliability is <75 (across all cases) and decides to appeal data elements. Complete the information identifying data elements to consider for appeal. Hospital to submit the completed Part One form to the local QIO no later than 10 business days after the validation results posted date.*

Do Not use separate forms for each data element/abstraction control number (tabbing from the last row will create a new row or additional pages within this document to enter information).

Hospital CCN: Hospital Name: Hospital State ID:

Hospital Contact Name: Telephone: ( )

Validation Qtr\Yr: / Form Completion Date by Hospital: / / Date QIO Received: / /

Patient ID Displayed on Validation Case Detail Report	Abstraction Control # Displayed on Validation Case Detail Repot	Discharge Date Displayed on Validation Case Detail Report	Measure Set Displayed on Validation Case Detail Report	Element Name Displayed on Validation Case Detail Report	Rationale Include justification why hospital believes data element was abstracted accurately. Supplemental information that was not included in the original medical record sent to the CDAC will not be considered.	QIO Use Only 1 2

1= Uphold CDAC Decision

2= Forward for Appeal (QIO to place only these elements onto Hospital Data Validation Appeal Form, Part Two)

*Submit form electronically to QIO contact via My QualityNet or via secure mail- DO NOT FAX.

This material was prepared by IFMC, Hospital Inpatient Quality Reporting Program Support Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. 9SoW-IA-HIQRP-11/10-138

Hospital Data Validation – Appeal Form

Released mm/dd/yyyy Part Two (QIO Use) Page 1