Form 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, and the hospital would like to request a
reconsideration, the hospital must complete and send 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). This form and the entire medical record must be received
by the Validation Support Contractor via the QualityNet Secure Portal Secure File Transfer “Validation Contractor” group, or via mail to:
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 0938-1109 (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.

Updated September 2019

Page 1 of 1