Form CMS-10432 Reconsideration Request Form

Quality Reporting Program
Reconsideration Request Form
When CMS determines that a facility did not meet the Quality Reporting Program
requirement(s), the facility may submit a request for reconsideration to CMS by the deadline
identified on the Annual Payment Update Notification Letter.
* Indicates required fields

Facility Contact Information
* Program Requesting Reconsideration: Inpatient __ Outpatient __ Psych __ Cancer __ ASC __
* Date of Request (MM/DD/YYY): ____/____/____
* CMS Certification Number (CCN): ______________________________________________________
* Facility Name: ______________________________________________________________________

Provide the facility’s CEO contact information. This will be used for official correspondence.
Please ensure within your organization that U.S. Mail and deliveries from overnight services that
are directed to this address will reach the necessary party(ies).
* CEO Last Name: ____________________________________________________________________
* CEO First Name: ____________________________________________________________________
* CEO Email Address: _________________________________________________________________
* CEO Address Line 1 (must include physical street address): __________________________________
____________________________________________________________________________________
CEO Address Line 2: __________________________________________________________________
____________________________________________________________________________________
* CEO City: __________________________________________________________________________
* CEO State: ____ *CEO Zip Code: _____-_____
* CEO Telephone Number: ___-___-____ ext. __________
Additional Contact Last Name: __________________________________________________________
Additional Contact First Name: __________________________________________________________
Additional Contact Email Address: _______________________________________________________
Additional Contact Address Line 1 (must include physical street address): ________________________
___________________________________________________________________________________
Additional Contact Address Line 2: _______________________________________________________
___________________________________________________________________________________
Additional Contact City: ________________________________________________________________
Additional Contact State: ____

Additional Contact Zip Code: _____-_____

Additional Contact Telephone Number: ___-___-____ ext. __________

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Quality Reporting Program
Reconsideration Request Form
Reconsideration Request Information
* Reason Facility Failed to Meet the Annual Payment Update Requirements: These details
were provided in the formal CMS notification letter that was sent to your CEO by the Centers for
Medicare & Medicaid Services (CMS).
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

* Reason for Reconsideration Request: Please state your reason for requesting
reconsideration.
You must identify the specific reason(s) for believing your facility did meet the Quality Reporting
Program requirement(s) and should receive the full annual payment update.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Additional information can be found at QualityNet.org
Additional Comments:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

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Quality Reporting Program
Reconsideration Request Form
Please send completed forms to the Inpatient Psychiatric Support Contractor:
• Via My QualityNet to the Global Exchange Group “Inpatient Psych QR Support Contractor”,
• Via secure FAX to Jane Tehel, Program Manager Telligen IPFQR Support (515)-558-5073,
or
• Via mail to:
Telligen IPFQR Support
1776 West Lakes Parkway
West Des Moines, IA 50266
Attn. Jane Tehel, Program Manager
DO NOT SEND THE COMPLETED FORM VIA EMAIL.

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 09381171. 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, and 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, Maryland 21244-1650.

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