CMS-10210 Validation Educational Review Form

Hospital Inpatient Quality Reporting (IQR) Program Validation Educational Review Form
Hospitals complete this form to request educational review of their validation results when discrepancies are found. Complete the information below from the
Case Detail Report (fields marked with an asterisk are required) and upload this form to the Value Incentives and Quality Reporting Center (VIQRC) Validation
Support Contractor via the QualityNet Secure Portal to the Validation Contractor group. For additional details, please see the Educational Review Process
document on the Inpatient Data Validation Educational Reviews page of QualityNet.
Hospital Provider CCN*: __________

Hospital Contact Name*: ________________________________________

Hospital Name*: ________________________________________________

E-mail Address*: ______________________________________________

Hospital State*: _______

Telephone*:

Validation Qtr. & Yr. (Example - 3Q15)*: ________

Date Submitted*:

_________________________
_________________________

Abstraction Control Number (ACN)*: ________________________________
NHSN Event ID: ____________________________ (if HAI Measure question)
Patient ID*:

____________________________

Admit Date*:

____________________________

Discharge Date*:____________________________
Measure Set*: ____________________________
Element Name*:____________________________
Rationale* (Please document your rationale for each review requested in the space below. Supplemental information that was not located in the original
Medical Record sent to the CMS Clinical Data Abstraction Center (CDAC) cannot be accepted, as the results of each of the reviews will be non-comparable.)

March 2017

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Abstraction Control Number (ACN): ________________________________
NHSN Event ID: ____________________________ (if HAI Measure question)
Patient ID:

____________________________

Admit Date:

____________________________

Discharge Date: ____________________________
Measure Set:

____________________________

Element Name: ____________________________
Rationale (Please document your rationale for each review requested in the space below. Supplemental information that was not located in the original Medical
Record sent to the CMS Clinical Data Abstraction Center (CDAC) cannot be accepted, as the results of each of the reviews will be non-comparable.)

Abstraction Control Number (ACN): ________________________________
NHSN Event ID: ____________________________ (if HAI Measure question)
Patient ID:

____________________________

Admit Date:

____________________________

Discharge Date: ____________________________
Measure Set:

____________________________

Element Name: ____________________________
Rationale (Please document your rationale for each review requested in the space below. Supplemental information that was not located in the original Medical
Record sent to the CMS Clinical Data Abstraction Center (CDAC) cannot be accepted, as the results of each of the reviews will be non-comparable.)

March 2017

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

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