Validation Review for Reconsideration Request
If the Centers for Medicare & Medicaid Services (CMS) determines that a hospital did not meet the Hospital Quality Program requirement(s) due to a confidence interval validation score less than 75%, hospitals must:
After completing this form please read the weblinks below for additional submission instructions:
For Inpatient Reconsideration Requirements: http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier3&cid=1184627418989
For Outpatient Reconsideration Requirements: http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier4&cid=1228694343534
CMS Certification Number (CCN): Hospital Name: State
Hospital Contact Name: Telephone:
Patient ID (Displayed on Case Detail report) |
Abstraction Control # (Displayed on Case Detail report) |
Encounter / Discharge Date(Displayed on Case Detail report) |
MeasureSet(Displayed on Case Detail report) |
Element Name (Displayed on Case Detail report) |
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. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Page 1
| File Type | application/msword |
| File Title | Hospital Outpatient Quality Reporting Program |
| Subject | Calendar Year 2012 Reconsideration Request Form (Part 2) |
| Author | FMQAI |
| Last Modified By | CTAC |
| File Modified | 2012-10-02 |
| File Created | 2012-10-02 |