Form CMS-10346 Request for Reconsideration

CMS-10346, OMB 0938-1129 (Expires: TBD)
Request for Reconsideration

Note: The QBP administrative review process is a two-step process which includes: 1) a request for reconsideration, and 2) a request for an
informal hearing after CMS has rendered its reconsideration decision. Both steps are conducted at the contract level. This first step affords
an MA organization the opportunity to request a reconsideration of how its Star Rating, for the given measure in question, was calculated.
This is not an opportunity for an MA organization to question how every measure was calculated. A request for reconsideration must be
submitted by the date and time specified below in order to reserve the right to later request an informal hearing on the record.
Instructions: Use only the “Request for Reconsideration” form that can be found in HPMS. To download a copy of the form from HPMS,
select Quality and Performance on the home page, then Performance Metrics. On the Performance Metrics page select Costs and then MA
QBP Rating. One form must be submitted for each contract for which reconsideration is requested. Each form may only be used for one
contract. Complete the identifiable information including all contact information. Please enable Macros in this form. Mark an “X” next to the
measure(s) that the MA Organization is questioning and requesting reconsideration. In the “Description of the Issue” specify any errors that
the MA Organization asserts CMS may have made in calculating the contract's QBP determination. Save the information, please include your
contract number in the filename and e-mail the completed form along with any additional documentary evidence to be considered to
[email protected] by the due date.
Due Date: A Request for Reconsideration of QBP is made by completing the Excel version of this form downloaded from HPMS and emailing the form to [email protected] by 5:00 p.m. EST on XXX. No late requests will be accepted.
Contract Number (5 character CMS assigned code):
Contact First Name (your first name):
Contact Last Name (your last name):
Contact Title (your job title):
Contact Phone Number (your phone number, include extension if necessary):
Contact email address (your email address):

QBP/Overall Rating

Overall Rating

Part C Measures
C01
C02
C03

Description of the Issue
(Please enter as much text as necessary to describe the reason you
Data Source Miscalculation Incorrect Data believe there was a Miscalculation and/or that Incorrect data were used)

Data Source

Miscalculation

Incorrect Data

Description of the Issue
(Please enter as much text as necessary to describe the reason you
believe there was a Miscalculation and/or that Incorrect data were used)

Part C Measures
C04
C05
C06
C07
C08
C09
C10
C11
C12
C13
C14
C15
C16
C17
C18
C19
C20
C21
C22
C23
C24
C25
C26
C27
C28
C29
C30
C31
C32
C33
C34

Data Source

Miscalculation

Incorrect Data

Description of the Issue
(Please enter as much text as necessary to describe the reason you
believe there was a Miscalculation and/or that Incorrect data were used)

D01
D02
D03
D04
D05
D06
D07
D08
D09
D10
D11
D12
D13
D14

Part C Measures

Data Source

Miscalculation

Incorrect Data

Description of the Issue
(Please enter as much text as necessary to describe the reason you
believe there was a Miscalculation and/or that Incorrect data were used)

Additional Comments (Please provide any additional information relevant to your request):

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 0938-1129 The time required to complete this information collection is estimated to average 8 hours, 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 estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C1-25-05, Baltimore, Maryland 21244-1850.