CMS-10250 Request for Reconsideration Part 2

Hospital Outpatient Quality Reporting Program
Calendar Year 2013 Reconsideration Request Form (Part 2)
If the Centers for Medicare & Medicaid Services (CMS) determines that a hospital did not meet the Hospital OQR Program requirements for calendar year (CY)
2013 due to a validation score less than 75%, cumulative of all cases across all 4 quarters, hospitals must:
1. Submit this completed form by fax to the Hospital OQR SC at 877-789-4443. Please Note: This form is only for Q2, Q3, Q4 2011 & Q1 2012 abstracted
cases affecting the CY 2013 payment determination. The hospital must submit completed forms to the Hospital OQR SC no later than February 3,
2013.
2. Submit the completed Reconsideration Request Form electronically via My QualityNet, using the file upload wizard and uploading to "Hospital OQR
Support Contractor."
Hospital Provider CCN: ____________________ Hospital Name: ____________________________________________________ State: ____________
Hospital Contact Name: ___________________________________________________________ Telephone: ______________________________________
Patient ID
(Displayed on
Case Detail
report)

Abstraction
Control #

Encounter
Date

Measure
Set

Element
Name

(Displayed on
Case Detail report)

(Displayed on
Case Detail
report)

(Displayed on
Case Detail
report)

(Displayed on
Case Detail report)

Rationale
Please provide written justification in the space below for each appealed data element classified as
a mismatch. Only data elements that affect a hospital’s validation score would be subject to
reconsiderations.

Date Received by Hospital OQR SC: __________________________
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-2013FS4T11-1-530
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Revised 01/23/2013