CMS-10210 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.

Facility Contact Information - * Indicates required fields

*Program Requesting Reconsideration: Inpatient Outpatient Psych Cancer ASC

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

*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 E-mail 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 E-mail 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.

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.

*Was your reason for not meeting the annual requirement(s) related to Validation? Yes No

PLEASE NOTE: Requests related to validation element mismatches for the clinical process measures require additional facility actions as follows:

• Complete the Validation Review for Reconsideration Request.

• Provide written justification for each data element you wish to appeal and

• Mail a copy of the entire medical record (as previously sent to the Clinical Data Abstraction Center (CDAC) contractor) for the appealed element(s).

• Medical records must be received by the deadline identified on the Annual Payment Update Notification letter.

Additional information can be found on QualityNet, http://www.qualitynet.org.

Additional Comments:

This material was prepared by Telligen, Hospital Inpatient Quality Reporting Program National Coordinating Center, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. 10SoW-IA-HIQRP-06/12-182

6/18/2012 Page 4 of 4