CMS-10210 Validation Educational Review Form

CMS Hospital Quality Reporting Validation Educational Review Request 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 Data Validation Educational Reviews pages of QualityNet.
Inpatient or Outpatient*: ______________________

Hospital Contact Name*: ________________________________________

Validation Qtr. & Yr. (Example - 3Q18)*: __________

E-mail Address*: ______________________________________________

Hospital Provider ID/CCN*: ______________

Telephone*:

Hospital State*: _________

Hospital Name*: ________________________________________________

____________________

Date Submitted*: ____________________

Abstraction Control Number (ACN)*: ____________________

Patient ID*:________________________________

Admit Date*: _________________________________ (if inpatient question)

Discharge Date*:___________________________ (if inpatient question)

Encounter Date*: ______________________________ (if outpatient question) NHSN Event ID* :___________________________ (if HAI Measure question)
Measure Set*: _____________________________________

Element Name*:____________________________

Rationale*: (Please document the rationale for each review requested for each case below. Provide any supporting page numbers, form names, symptoms, etc.
from the medical record originally submitted to Clinical Data Abstraction Center (CDAC), including any questions or reasons for disputing the rationale; being as
detailed as possible. If the rationale is blank, the form will be returned for it to be completed. Supplemental information that was not located in the original
medical record sent to the CDAC cannot be accepted, as the results of each of the reviews will be non-comparable.)

If submitting more than one question, you may use the pages below. If submitting more than five questions, another form may be submitted.

3/2020

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Abstraction Control Number (ACN)*: ____________________

Patient ID*:________________________________

Admit Date*: _________________________________ (if inpatient question)

Discharge Date*:___________________________ (if inpatient question)

Encounter Date*: ______________________________ (if outpatient question) NHSN Event ID* :___________________________ (if HAI Measure question)
Measure Set*: _____________________________________

Element Name*:____________________________

Rationale*:

Abstraction Control Number (ACN)*: ____________________

Patient ID*:________________________________

Admit Date*: _________________________________ (if inpatient question)

Discharge Date*:___________________________ (if inpatient question)

Encounter Date*: ______________________________ (if outpatient question) NHSN Event ID* :___________________________ (if HAI Measure question)
Measure Set*: _____________________________________

Element Name*:____________________________

Rationale*:

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Abstraction Control Number (ACN)*: ____________________

Patient ID*:________________________________

Admit Date*: _________________________________ (if inpatient question)

Discharge Date*:___________________________ (if inpatient question)

Encounter Date*: ______________________________ (if outpatient question) NHSN Event ID* :___________________________ (if HAI Measure question)
Measure Set*: _____________________________________

Element Name*:____________________________

Rationale*:

Abstraction Control Number (ACN)*: ____________________

Patient ID*:________________________________

Admit Date*: _________________________________ (if inpatient question)

Discharge Date*:___________________________ (if inpatient question)

Encounter Date*: ______________________________ (if outpatient question) NHSN Event ID* :___________________________ (if HAI Measure question)
Measure Set*: _____________________________________

Element Name*:____________________________

Rationale*:

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 (Expires 12/31/2022).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 Disclosure**** 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].

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