CMS-10210 IQR Reconsideration Request Form

Quality Reporting Program
Reconsideration Request Form
When the Centers for Medicare & Medicaid Services (CMS) determines that a facility did not
meet the Quality Reporting Program requirement(s) for the Annual Payment Update (APU), the
facility may submit a request for reconsideration to CMS by the deadline identified on the APU
Notification letter.
*Indicates required field

*Facility Information:
*Program Requesting Reconsideration: Inpatient __ Psych __ Outpatient __ ASC __
*Date of Request (MM/DD/YYYY): ____/____/_____
*CMS Certification Number (CCN) (Not required for ASC): __________________
*National Provider Identification (NPI) (Required for ASC only): ________________________
*Facility Name: _______________________________________________________________

*CEO Contact Information (Designated Contact Information for Outpatient and
ASC only):
Please ensure within your organization that U.S. Mail and deliveries from overnight services
directed to this address will reach the necessary party.
*Name: _____________________________________________________________________
*Email Address: ______________________________________________________________
*Telephone Number: ______-______-_______ Ext. __________
*Mailing Address (must include physical address; P.O. Box addresses are not valid):
____________________________________________________________________________
*City: ________________________________________________________________________
*State: ____

*ZIP Code: __________-_______

*QualityNet System Administrator Contact Information (Not required for ASC):
*Name: _____________________________________________________________________
*Email Address: ______________________________________________________________
*Telephone Number: ______-______-_______ Ext. __________
*Mailing Address (must include physical street address; P.O. Box addresses are not valid):
____________________________________________________________________________
*City: _______________________________________________________________________
*State: ____

*ZIP Code: __________-_______

Updated January 2015

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Quality Reporting Program
Reconsideration Request Form
*Reconsideration Request Information:
*CMS-Identified Reason Facility Did Not Meet the APU Requirements: These details were
provided in the formal CMS notification letter that was sent to the facility.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

*Reason for Reconsideration Request: Please state your facility’s reason for requesting
reconsideration. This must identify the specific reason(s) for believing your facility did meet the
Quality Reporting Program requirements and should receive the full APU.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Paper Medical Record Requirement for Reconsideration Requests Involving Validation: If
a facility requests CMS to reconsider an adverse Quality Reporting Program payment decision
made because the facility did not meet the validation requirement, the facility must submit paper
copies of all the medical records that it submitted to the Clinical Data Abstraction Center
(CDAC) contractor for purposes of the validation. Facilities submitting a Quality Reporting
Program validation reconsideration request will have all data elements to be reconsidered
reviewed by CMS. Facilities must provide a written justification for each appealed data element
classified during the validation process as a mismatch. CMS will review the data elements that
were labeled as mismatched, as well as the written justifications provided by the facilities, and
make a decision on the reconsideration request.
Complete and submit this form via the QualityNet Secure Portal, Secure File Transfer
“APU” group, via secure fax to 877-789-4443, or email to [email protected].
Following receipt of the request form, an email acknowledgement will be sent confirming the
form has been received. Once a determination has been made, CMS will provide the formal
decision regarding the request.
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 0938-1022.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, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy
of the time estimates(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, MD 21244-1650.

Updated January 2015

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