CMS-10250 Validation Review for Reconsideration Request

CMS Hospital OQR Program
Validation Review for Reconsideration Request
If the Centers for Medicare & Medicaid Services (CMS) determines that a hospital did not meet any of the Hospital Outpatient Quality
Reporting (OQR) Program requirements due to a confidence interval validation score of less than 75 percent, the hospital must
complete and submit this form, along with a copy of the entire medical record (as previously sent to the Clinical Data Abstraction
Center [CDAC] Contractor) for the appealed element(s), to the Validation Contractor at:
Telligen
Attn: Validation Support Contractor
1776 West Lakes Parkway
West Des Moines, IA 50266
CMS Certification Number (CCN):

Hospital Name:

Hospital Contact Name:

State:
Telephone:
Rationale

Patient
ID*

Abstraction
Control #*

Encounter/
Discharge
Date*

Measure
Set*

Element
Name*

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.

*Please Note: These elements are displayed on the Case Detail Report.
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 July 2015

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