Form CMS-10346 Request for Reconsideration

Attachment A
Request for Reconsideration

Note: The QBP administrative review process is a two-step process which includes: 1) a request for reconsideration, and 2) a request for an informal hearing after CMS has rendered its reconsideration decision. Both steps are
conducted at the contract level. This first step affords an MA organization the opportunity to request a reconsideration of how its Star Rating, for the given measure in question, was calculated. This is not an opportunity for an MA
organization to question how every measure was calculated. A request for reconsideration must be submitted by the date and time specified below in order to reserve the right to later request an informal hearing on the record.
Instructions: Use only the “Request for Reconsideration” form that can be found in HPMS. To download a copy of the form from HPMS, select Quality and Performance in the left navigation bar, then Part C Performance Metrics and
then Quality Bonus Payment Rating. One form must be submitted for each contract for which reconsideration is requested. Each form may only be used for one contract. Complete the identifiable information including all contact
information. Please enable Macros in this form. Mark an “X” next to the measure(s) that the MA Organization is questioning and requesting reconsideration. In the “Description of the Issue” specify any errors that the MA Organization
asserts CMS may have made in calculating the contract's QBP determination. Save the information, please include your contract number in the filename and e-mail the completed form along with any additional documentary evidence to
be considered to [email protected] by the due date.
Due Date: A Request for Reconsideration of QBP is made by completing the Excel version of this form downloaded from HPMS and e-mailing the form to [email protected] by 5:00 p.m. EST on November 26, 2013. No late
requests will be accepted.
Contract Number (5 character CMS assigned code):
Contact First Name (your first name):
Contact Last Name (your last name):
Contact Title (your job title):
Contact Phone Number (your phone number, include extension if necessary):
Contact email address (your email address):
Request for Reconsideration
Overall Rating

Data Source

Miscalculation

QBP/Overall Rating

Incorrect Data
Not Appealable

Request for Reconsideration
Part C Measures
C01 - Breast Cancer Screening
C02 - Colorectal Cancer Screening
C03 - Cardiovascular Care – Cholesterol Screening
C04 - Diabetes Care – Cholesterol Screening
C05 - Glaucoma Testing
C06 - Annual Flu Vaccine
C07 - Improving or Maintaining Physical Health
C08 - Improving or Maintaining Mental Health
C09 - Monitoring Physical Activity
C10 - Adult BMI Assessment
C11 - Care for Older Adults – Medication Review
C12 - Care for Older Adults – Functional Status Assessment
C13 - Care for Older Adults – Pain Screening
C14 - Osteoporosis Management in Women who had a Fracture
C15 - Diabetes Care – Eye Exam
C16 - Diabetes Care – Kidney Disease Monitoring
C17 - Diabetes Care – Blood Sugar Controlled
C18 - Diabetes Care – Cholesterol Controlled
C19 - Controlling Blood Pressure
C20 - Rheumatoid Arthritis Management
C21 - Improving Bladder Control
C22 - Reducing the Risk of Falling

Data Source
HEDIS
HEDIS
HEDIS
HEDIS
HEDIS
CAHPS
HOS
HOS
HEDIS / HOS
HEDIS
HEDIS
HEDIS
HEDIS
HEDIS
HEDIS
HEDIS
HEDIS
HEDIS
HEDIS
HEDIS
HEDIS / HOS
HEDIS / HOS

Miscalculation

Incorrect Data
Not Appealable
Not Appealable
Not Appealable
Not Appealable
Not Appealable
Not Appealable
Not Appealable
Not Appealable
Not Appealable
Not Appealable
Not Appealable
Not Appealable
Not Appealable
Not Appealable
Not Appealable
Not Appealable
Not Appealable
Not Appealable
Not Appealable
Not Appealable
Not Appealable
Not Appealable

Description of the Issue
(Please enter as much text as necessary to describe the reason you believe there
was a Miscalculation and/or that Incorrect data were used)

Description of the Issue
(Please enter as much text as necessary to describe the reason you believe there
was a Miscalculation and/or that Incorrect data were used)

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Attachment A
C23 - Plan All-Cause Readmissions
C24 - Getting Needed Care
C25 - Getting Appointments and Care Quickly
C26 - Customer Service
C27 - Rating of Health Care Quality
C28 - Rating of Health Plan
C29 - Care Coordination
C30 - Complaints about the Health Plan
C31 - Beneficiary Access and Performance Problems
C32 - Members Choosing to Leave the Plan
C33 - Health Plan Quality Improvement
C34 - Plan Makes Timely Decisions about Appeals
C35 - Reviewing Appeals Decisions
C36 - Call Center – Foreign Language Interpreter and TTY Availability

HEDIS
CAHPS
CAHPS
CAHPS
CAHPS
CAHPS
CAHPS
CTM
CMS Administrative
Data
Medicare Beneficiary
Database Suite of
Systems
Star Ratings
IRE
IRE
Call Center

Not Appealable
Not Appealable
Not Appealable
Not Appealable
Not Appealable
Not Appealable
Not Appealable
Not Appealable

Not Appealable
Not Appealable

Request for Reconsideration
Part D Measures
D01 - Call Center – Foreign Language Interpreter and TTY Availability
D02 - Appeals Auto–Forward
D03 - Appeals Upheld
D04 - Complaints about the Drug Plan
D05 - Beneficiary Access and Performance Problems
D06 - Members Choosing to Leave the Plan
D07 - Drug Plan Quality Improvement
D08 - Rating of Drug Plan
D09 - Getting Needed Prescription Drugs

D10 - MPF Price Accuracy

D11 - High Risk Medication
D12 - Diabetes Treatment

Data Source
Call Center
IRE
IRE
CTM
CMS Administrative
Data
Medicare Beneficiary
Database Suite of
Systems
Star Ratings
CAHPS
CAHPS
PDE data, MPF Pricing
Files, HPMS approved
formulary extracts, and
data from First
DataBank and
Medispan
Prescription Drug Event
(PDE) data
Prescription Drug Event
(PDE) data

Description of the Issue
(Please enter as much text as necessary to describe the reason you believe there
was a Miscalculation and/or that Incorrect data were used)

Miscalculation

Incorrect Data

Not Applicable

Not Applicable

Not appealable, use Part C measure C30 above.

Not Applicable

Not Applicable

Not appealable, use Part C measure C31 above.

Not Applicable

Not Applicable

Not appealable, use Part C measure C32 above.

Not Appealable
Not Appealable
Not Appealable

Not Appealable

Not Appealable
Not Appealable

D13 - Part D Medication Adherence for Diabetes Medications

Prescription Drug Event
(PDE) data; Inpatient
(IP) Data File

Not Appealable

D14 - Part D Medication Adherence for Hypertension (RAS antagonists)

Prescription Drug Event
(PDE) data; Inpatient
(IP) Data File

Not Appealable

D15 - Part D Medication Adherence for Cholesterol (Statins)

Prescription Drug Event
(PDE) data; Inpatient
(IP) Data File

Not Appealable

Additional Comments (Please provide any additional information relevant to your request)

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Attachment A

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 09381129. The time required to complete this information collection is estimated to average 8 hours, 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 C1-25-05,
Baltimore, Maryland 21244-1850.

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