Form CMS-10250 Notice of Participation Form

OQR Notice of Participation Overview
OQR Notice of Participation | Menu
Provider Name
ABC HOSPITAL
Provider ID
XXXXXX

Medicare Accept Date
07/01/1974

Notice of Participation
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Notice of Participation
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Facility Close Date

OQR Notice of Participation | Summary
Provider Name
ABC HOSPITAL
Provider ID
XXXXXX

Medicare Accept Date
07/01/1974

Facility Close Date

Notice of Participation Summary Table
Paymen
t Year
2016

Notice of
Participation
Status
Participating

2015

Participating

2014

Participating

2013

Participating

2012

Participating

2011

Participating

2010

Participating

Notice of
Participation
Date
01/03/2008
21:00:00 PT
01/03/2008
21:00:00 PT
01/03/2008
21:00:00 PT
01/03/2008
21:00:00 PT
01/03/2008
21:00:00 PT
01/03/2008
21:00:00 PT
01/03/2008
21:00:00 PT

Added By

Date Edited

Edited By

06/20/2012
14:36:46
03/05/2012
07:57:03
03/05/2012
07:57:03
03/05/2012
07:57:03
12/18/2008
10:15:58

PROD_DATA_MGT

CARRY_FORWARD
CARRY_FORWARD
LOAD_PROC
LOAD_PROC
LOAD_PROC
LOAD_PROC
LOAD_PROC

PROD_DATA_MGT
PROD_DATA_MGT
PROD_DATA_MGT
OPLEDGE_APP_USER

Comments

OQR Notice of Participation | Text
Provider Name
ABC HOSPITAL
Provider ID
XXXXXX

Medicare Accept Date
07/01/1974

Facility Close Date

OQR Notice of Participation Text
Review the Notice of Participation below, choose an option and enter your acknowledgement to confirm.
Hospital Outpatient Quality Reporting Program Notice of Participation
Hospitals defined under section 1886(d)(1)(B) of the Social Security Act, known as sub-section(s) hospitals that
are paid under the Hospital Outpatient Quality Reporting Program (OQR) requirements. Those hospitals that do
not follow the guidelines as outlined in the Federal Register may receive a reduction in the Medicare Annual
Payment Update (APU) for the applicable Calendar Year based on the Final Rule. To avoid the reduction in the
APU, sub-section(d)k hospitals reimbursed under the OQR must acknowledge a Pledge of Participation
including acknowledgement that their reported quality information may be accessible for public viewing as
required by Section 1833(t)(17)(E) of the Social Security Act. All OQR requirements are also summarized in
the OQR References Checklist available on QualityNet.org.
Hospitals that are not classified as sub-section(d) hospitals (e.g. Critical Access and other non-PPS hospitals) or
are subsection (d) hospitals not paid under the OQR (e.g. Indian Health Services hospitals) may also participate
in OQR. For these hospitals, outpatient services reimbursement is not at risk, but to submit data under the
program, submission of a complete Pledge of Participation is necessary. If a hospital is participating and wants
to withdraw, an acknowledgement of a request to withdraw is required.
In the event that the Center for Medicare & Medicaid Services (CMS) makes such information available to the
public for viewing, hospitals will be provided the opportunity to preview their information as it is recorded. All
such data will be aggregated as determined by CMS.
Under the HQA initiative, data is submitted and catalogued by the CMS Certification Number (Provider ID).
Any pledge to participate, not participate, withhold data or withdraw from participation applies to all entities
reimbursed under the specified Provider ID.
We entities operating under the submitted Provider ID: XXXXXX
We (entities operating under the submitted Provider ID) agree to participate. (We agree to follow the
procedures for participating in the Hospital Outpatient Quality Reporting Program (OQR) as outlined in
the Federal Register.)
We (entities operating under the submitted Provider ID) do not agree to participate from the
previous Pledge.
We (entities operating under the submitted Provider ID) request to be withdrawn from the previous
Pledge.

This acknowledgement (to participate or not to participate/withdraw) remains in effect until an electronically
signed acknowledgement applying changes has been entered.

By entering my acknowledgement, I hereby issue this OQR Notice of Participation with the specified
direction contained within:

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 0938-1109 (Expiration date: 10/31/2020). 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 estimate(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, Maryland 21244-1850. *****CMS Disclaimer*****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 Outpatient Quality Reporting Program Support at
866.800.8756.