CMS-10210 Validation Review for Reconsideration Request

CMS Hospital IQR 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 Inpatient Quality Reporting
(IQR) Program requirements due to a confidence interval validation score of less than 75 percent and the hospital would like to request a
reconsideration, the hospital must complete and mail this form, along with a paper copy of the entire medical record (as previously sent to the
Clinical Data Abstraction Center [CDAC] Contractor) for the appealed element(s). This form and the entire medical record must be received by the
Validation Support Contractor, within 30 days following the date of receipt of the Hospital IQR Program Annual Payment Update (APU)
Notification Letter, 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: Please provide written justification in the space below for each
Patient
ID*

Abstraction
Control #*

Encounter/
Discharge
Date*

Measure
Set*

Element
Name*

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.

*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. Please do not send applications, claims, payments, medical records, or any documents
containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB
control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Validation Support
Contractor at [email protected]. Expiration Date: XX-XX-XXXX

March 2017