CMS-10210 Validation Review for Reconsideration Request

Hospital Quality Reporting Program
Validation Review for Reconsideration Request
If the Centers for Medicare & Medicaid Services (CMS) determines that a hospital did not meet the Hospital Quality Program requirement(s) due to
a confidence interval validation score less than 75%, hospitals must:
•

After completing this form please read the weblinks below for additional submission instructions:

For Inpatient Reconsideration Requirements:
http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier3&cid=1184627418989
For Outpatient Reconsideration Requirements:
http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier4&cid=1228694343534

CMS Certification Number (CCN): _________ Hospital Name: ___________________________________________________ State ____________
Hospital Contact Name: ___________________________________________________________ Telephone: ______________________________________
Patient ID
(Displayed on
Case Detail
report)

Abstraction
Control #
(Displayed on
Case Detail report)

Encounter /
Discharge
Date
(Displayed on
Case Detail
report)

Measure
Set

Element
Name

(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. Mismatched data elements that affect a hospital’s validation score would be subject to
reconsiderations. Supplemental information that was not located in the original medical record sent
to the CMS Clinical Data Abstraction Center (CDAC) cannot be accepted.)

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-06/12-183
6/18/2012

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