CMS-10250 Request for Reconsideration Part 1

Hospital Outpatient Quality Reporting Program
Calendar Year 2013 Reconsideration Request Form (Part 1)
All Sections Are Required to Be Completed
Hospital ID: ___________________
Hospital Name: _____________________________________________________________
Reason Hospital Failed to Meet the Calendar Year (CY) 2013 Requirements: (These details
were provided in the formal CMS notification letter that was sent to your CEO or designated
hospital personnel by the Centers for Medicare & Medicaid Services (CMS); see sample letter of
notification on QualityNet.org.)

Reason for Reconsideration Request: Please state your reason for requesting reconsideration.
You must identify the specific reason(s) for believing your hospital did meet the Hospital OQR
Program requirements and should receive the full CY 2013 OPPS annual payment update.
(Limited to 4,950 characters)

CEO or Designated Hospital Personnel Contact Information (Required): This information
will be used for official correspondence. Please ensure within your organization that mail
directed to this address will reach the necessary party or parties.
CEO or Designee Name:
_______________________________________________________
CEO or Designee E-Mail Address:
_______________________________________________________

Revised 01/23/2013

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CEO or Designee Telephone Number:
_____________________________________________________
CEO or Designee Mailing Address (include physical address as well as PO Box):
___________________________________________________________________________
___________________________________________________________________________
City _____________________________ State ________ ZIP Code ___________________
Additional Contact Information
Name: ________________________________________________
E-Mail Address: ________________________________________
Telephone Number: _____________________________________
Mailing Address (include physical address as well as PO Box):
________________________________________________________________________
________________________________________________________________________
City _______________________________ State _______ ZIP Code ________________

*Signature of CEO or Designee _____________________________________
Date ________________
*Not required for submission
Complete this form electronically and upload it via the QualityNet File Upload wizard to
“Hospital OQR Support Contractor”; save the CEO- or Designee-signed copy for your records.
Faxes are not accepted.
For reconsiderations related to validation scores less than 75 percent, please submit
healthcare documentation following the process stated on http://www.QualityNet.org.

This material was prepared by FMQAI, the Support Center for the Hospital
Outpatient Quality Reporting program, under contract with the Centers for
Medicare & Medicaid Services (CMS), an agency of the U.S. Department of
Health and Human Services (HHS). The contents presented do not necessarily
reflect CMS policy. FL-10SOW-2013FS4T11-1-529

Revised 01/23/2013

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