Inquiry Crosswalk

Revisions to Form CMS-10752 Submissions of 1135 Waiver Request Inquiry Webform

Issue #	Page #	Section	Action to be performed	Changes to the Application	Reason for the Change
	13-21	Organization Workflow Top of Inquiry Web Form	Revise as follows:	Replace: “Under Section 1135 or 1812(f) of the Social Security Act, CMS can issue several blanket waivers when there's a disaster or emergency. Blanket waivers prevent gaps in the access to care for beneficiaries affected by the emergency. When a blanket waiver is issued, providers don't have to apply for an individual waiver. If there's no blanket waiver, providers can ask for an individual Section 1135 waiver. If you have a request or inquiry, please use this form to submit your request to CMS.” With: “If you have a request or inquiry, please use this form to submit your request to CMS.”	Updated instructional text to match the submission of an Inquiry.
	13-21	Organization Workflow Who are you?	New - add as follows:	Add question mark help text: “This information helps CMS understand who you are so we can better assist you.”	Added help text to aid users in completing the submission.
	13-21	Organization Workflow What would you like to do?	New – add as follows:	Add question mark help text: “Choose the applicable option below.”	Added help text to aid users in completing the submission.
	13-21	Organization Workflow What would you like to do? Selection options	Revise as follows:	Replace selection options: I want to submit a waiver / flexibility request I want to submit an inquiry request With these 3 selection options: I want to submit a waiver / flexibility request I want to submit an inquiry I want to provide a status update on my beneficiaries and/or healthcare facility	Added new option for HCF path
	13-21	Organization Workflow What would you like to do?	New - add as follows:	Add question mark help text for selection option, “I want to submit a waiver / flexibility request”: “When there’s a disaster or emergency, waivers and flexibilities help health care facilities give timely care to as many people who’ve been affected as possible. This means we’re helping States, Federal Districts and U.S. territories to make sure people with Medicare and/or Medicaid continue to have access to care. “Waiver” refers to a waiver or modification of a statutory requirement of the Social Security Act (Act) or its implementing regulations that may be waived or modified under the authority of § 1135 of the Act or § 1812(f). A “flexibility” is an agency policy or procedure that can be adjusted under current authority – and generally speaking, can be adjusted without reprogramming CMS’s systems. CMS will implement these waivers and flexibilities as necessary and appropriate to accommodate the needs of those impacted by an emergency or disaster.”	Added help text to aid users in completing the submission.
	13-21	Organization Workflow What would you like to do?	New - add as follows:	Add question mark help text for selection option, “I want to submit an inquiry”: “When there’s a disaster or emergency, waivers and flexibilities help health care facilities give timely care to as many people who’ve been affected as possible. This means we’re helping States, Federal Districts and U.S. territories to make sure people with Medicare and/or Medicaid continue to have access to care.”	Added help text to aid users in completing the submission.
	13-21	Organization Workflow What would you like to do?	New - add as follows:	Add question mark help text for selection option, “I want to provide a status update on my beneficiaries and/or healthcare facility”: “You may use this option to report any impact on normal operations.”	Added help text to aid users in completing the submission.
	13-21	Organization Workflow Submit an Inquiry Select a Public Health Emergency	New - add as follows:	Add question mark help text to field, “Public Health Emergency (PHE)”: “Select the applicable Public Health Emergency from the dropdown list.”	Added help text to aid users in completing the submission.
	13-21	Organization Workflow Provide Your Contact Information Point of Contact field	New - add as follows:	Add question mark help text to, “Point of Contact” field: “CMS uses your contact information to send responses and ask follow up questions.”	Added help text to aid users in completing the submission.

	13-21	Organization Workflow Provide Your Contact Information Zip Code field	New - add as follows:	Add “Zip Code” field (mandatory) This field is mandatory. This field is placed below the “Last name” field and above the “Phone number” field. Add question mark help text: “Please enter your 5-digit zip code.” Add ghost text: “XXXXX”	Added Zip Code to ensure accuracy of submitter location information. Added help text to aid users in completing the submission. Added ghost text to aid users in completing the submission.
	13-21	Organization Workflow Provide Your Contact Information Phone number field	New - add as follows:	Add ghost text for “Phone number” field: “(XXX)XXX-XXXX”	Added ghost text to aid users in completing the submission.
	13-21	Organization Workflow Provide Your Contact Information Organization Information	New - add as follows:	Add new section, “Organization Information” Add question mark help text: “An organization is an organized body of people with a particular purpose (e.g., State, Corporation, Health System, etc.). Please provide the required information for your organization.” Add instruction help text: “Who is the organization making this request?”	This information allows the system to automatically route requests to the correct CMS respondent, thereby allowing CMS to respond more quickly to the submitter.

	13-21	Organization Workflow Provide Your Contact Information Organization Name	New - add as follows:	Add new field, “Organization Name” This field is mandatory. This field is placed below “Organization Information” and above “Organization Categories”	This information allows the system to automatically route requests to the correct CMS respondent, thereby allowing CMS to respond more quickly to the submitter.
	13-21	Organization Workflow Provide Your Contact Information Organization Categories	New – add as follows:	Add new field, “Organization Categories” This field is mandatory. This field is placed below “Organization Name” field and above the tabbed options for selection. Add question mark help text: “This provides CMS additional information on the type of organization requesting a inquiry. Please select all applicable organizations by reviewing the data on all three tabs (At least one category must be selected).” Add instruction help text: “Who is the organization making this request?”	This information allows the system to automatically route requests to the correct CMS respondent, thereby allowing CMS to respond more quickly to the submitter.
	13-21	Organization Workflow Provide Your Contact Information Organization Categories General Tab	New - add as follows:	Add 1st tab, “General” Add the following checkboxes on this tab: Advocacy Group Association Corporation Medicare Advantage/Part D Plan State Government Qualified Health Plan State Medicaid Agency State Survey Agency Tribal Nation	This information allows the system to automatically route requests to the correct CMS respondent, thereby allowing CMS to respond more quickly to the submitter.
	13-21	Organization Workflow Provide Your Contact Information Organization Categories Emergency Provider / Supplier Types tab	New - add as follows:	Add 2nd tab, “Emergency Provider / Supplier Types” Add the following checkboxes on this tab: Ambulatory Surgical Center (ASC) Community Mental Health Center (CMHC) Comprehensive Outpatient Rehabilitation Facility (CORF) Critical Access Hospital (CAH) Community Mental Health Center (CMHC) End Stage Renal Disease (ESRD) Home Health Agencies (HHA) Hospice Hospital Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) Nursing Homes (SNF/NF) Organ Procurement Organization (OPO) Outpatient Physical Therapy/Speech Therapy (OPT/ST) Programs of All-Inclusive Care for Elderly (PACE) Psychiatric Residential Treatment Facility (PRTF) Religious Non-Medical Health Care Institution (RNCHI) Rural Health Clinic/Federally Qualified Health Center (RHC/FQHC) Transplant Center	This information allows the system to automatically route requests to the correct CMS respondent, thereby allowing CMS to respond more quickly to the submitter.
	13-21	Organization Workflow Provide Your Contact Information Organization Categories Other tab	New - add as follows:	Add 3rd tab, “Other” Add the following checkboxes on this tab: Ambulance Durable Medical Equipment (DME) Lab Other Palliative Physician Other (if selected, "Other Organization Category" input box is made visible and editable and mandatory)	This information allows the system to automatically route requests to the correct CMS respondent, thereby allowing CMS to respond more quickly to the submitter.
	13-21	Organization Workflow Provide Your Contact Information Organization Identification Numbers	New - add as follows:	Add section, “Organization Identification Numbers” Add question mark help text: “Indicate all applicable identification numbers for the healthcare facilities/providers affiliated with your organization impacted by the PHE.” Add instruction help text: “What are the identification numbers for your organization? These numbers will be different, depending on the categories you have selected for your organization including: CCN/Provider, Medicare Contract Number, or NPI. For the categories selected above, use:”	This information allows the system to automatically route requests to the correct CMS respondent, thereby allowing CMS to respond more quickly to the submitter.

	13-21	Organization Workflow Provide Your Contact Information Organization Identification Numbers	New - add as follows:	Add “IDENTIFICATION NUMBER” field (not mandatory) Add ghost help text: “Separate multiple identification numbers with a comma.”	This information allows the system to automatically route requests to the correct CMS respondent, thereby allowing CMS to respond more quickly to the submitter.
	13-21	Organization Workflow Inquiry	New – add as follows:	Allow for multiple Inquiry requests in one web form submission. Add label, “Request #1” and as each submission is made a new section opens up with the Topic, Type, and Description fields visible and editable and the subsequent request is named appropriately, “Request #2, Request #3, etc.”	Added the ability to submit multiple requests in a single submission to ease the burden on users by streamlining the submission process.
	13-21	Organization Workflow Inquiry Topic	Revise as follows:	Replace “Inquiry Topic” field name with “Topic” The field is mandatory. “Topic” field values are: Medicaid/CHIP Original Medicare (Part A or B) Medicare Advantage/Prescription Drug Plan Qualified Health Plans Add question mark help text: “Choose from the dropdown list which category your inquiry would fall under.”	Simplified the field label.
	13-21	Organization Workflow Inquiry Type	Revise as follows:	Replace “Inquirer Type” field name with “Type” This field is mandatory. “Type” field values are: 638 Tribal Clinics Academia Access To Care Advocate Ambulance Ambulatory Care Center Appeals Appendix K Association/Society for Provider/Facility Attorney for Provider/Facility Billing Agency Consultant for Provider/Facility Critical Access Hospital Denials Dialysis Facility Eligibility Employer Facility Fair Hearings Federal/State Government Agency Federally Qualified Health Center (FQHC) General Public HCBS Waivers Home Health Hospice Hospital Insurance Company Long Term Care Services And Supports Managed Care Medical Supplier/DME Nurse/Nurse Practitioner Nursing Home Other Payment Methodology/Rates Pharmacist/Pharmacy Physical/Occupational Therapy Physician Physician Assistant Provider – Mental Health Provider - Other Provider Enrollment Respite Retainer Payments Rural Health Clinic Rural Health Clinic (RHC) Skilled Nursing Facility State Agency Telehealth The “Type” field is placed below the “Topic” field. Add question mark help text: “Choose your inquiry type from the dropdown list.” Add checkbox field, “Click here if you do not see your type” If the checkbox is true, then input box is made visible, editable, and mandatory.	Simplified the field label. Added help text to aid users in completing the submission. This checkbox was added to give users a mechanism for indicating an inquiry type not represented in the selectable options.
	13-21	Organization Workflow Inquiry Description	New - add as follows:	Add field, “Description” This field is mandatory. Add ghost help text: “Provide a comprehensive description of your inquiry (including regulation citations if applicable). Add a link for the submitter to select to open up the Topic, Type, and Description field for entry of next Inquiry request, “+ Add another inquiry request”	This information allows CMS to understand the nature of the inquiry in order to provide an accurate response. Added ghost text to aid users in completing the submission. Added a link to allow users to submit multiple requests in a single submission to ease the burden on users by streamlining the submission process.
	13-21	Organization Workflow Footer: Warning message	Revise as follows:	Replace: “For detailed information regarding transmitting or receiving healthcare information or data read the QualityNet System Security Policy (PDF). With: “For detailed information regarding safeguarding protected healthcare information or data, please refer to the ""HIPAA Security Rule"" (https://www.hhs.gov/hipaa/for-professionals/index.html).	Corrected the reference to QualityNet System Security policy to the HIPAA Security Rule.
	22-29	Beneficiary Workflow Top of Inquiry Web Form	Revise as follows:	Replace: “Under Section 1135 or 1812(f) of the Social Security Act, CMS can issue several blanket waivers when there's a disaster or emergency. Blanket waivers prevent gaps in the access to care for beneficiaries affected by the emergency. When a blanket waiver is issued, providers don't have to apply for an individual waiver. If there's no blanket waiver, providers can ask for an individual Section 1135 waiver. If you have a request or inquiry, please use this form to submit your request to CMS.” With: “If you have a request or inquiry, please use this form to submit your request to CMS.”	Updated instructional text to match the submission of an Inquiry.
	22-29	Beneficiary Workflow Who are you?	Revise as follows:	Add question mark help text: “This information helps CMS understand who you are so we can better assist you.”	Added help text to aid users in completing the submission.
	22-29	Beneficiary Workflow What would you like to do?	New - add as follows:	Add question mark help text: “Choose the applicable option below.”	Added help text to aid users in completing the submission.
	22-29	Beneficiary Workflow What would you like to do? Selection options	New - add as follows:	Replace selection options: I want to submit a waiver / flexibility request I want to submit an inquiry request With these 3 selection options: I want to submit a waiver / flexibility request I want to submit an inquiry I want to provide a status update on my beneficiaries and/or healthcare facility	Added new option for HCF path.
	22-29	Beneficiary Workflow What would you like to do?	New - add as follows:	Add question mark help text for selection option, “I want to submit a waiver / flexibility request”: “When there’s a disaster or emergency, waivers and flexibilities help health care facilities give timely care to as many people who’ve been affected as possible. This means we’re helping States, Federal Districts and U.S. territories to make sure people with Medicare and/or Medicaid continue to have access to care. “Waiver” refers to a waiver or modification of a statutory requirement of the Social Security Act (Act) or its implementing regulations that may be waived or modified under the authority of § 1135 of the Act or § 1812(f). A “flexibility” is an agency policy or procedure that can be adjusted under current authority – and generally speaking, can be adjusted without reprogramming CMS’s systems. CMS will implement these waivers and flexibilities as necessary and appropriate to accommodate the needs of those impacted by an emergency or disaster.”	Added help text to aid users in completing the submission.
	22-29	Beneficiary Workflow What would you like to do?	New - add as follows:	Add question mark help text for selection option, “I want to submit an inquiry”: “When there’s a disaster or emergency, waivers and flexibilities help health care facilities give timely care to as many people who’ve been affected as possible. This means we’re helping States, Federal Districts and U.S. territories to make sure people with Medicare and/or Medicaid continue to have access to care.”	Added help text to aid users in completing the submission.
	22-29	Beneficiary Workflow What would you like to do?	New - add as follows:	Add question mark help text for selection option, “I want to provide a status update on my beneficiaries and/or healthcare facility”: “You may use this option to report any impact on normal operations.”	Added help text to aid users in completing the submission.
	22-29	Beneficiary Workflow Submit an Inquiry Select a Public Health Emergency	Revise as follows:	Add question mark help text to field, “Public Health Emergency (PHE)”: “Select the applicable Public Health Emergency from the dropdown list.”	Added help text to aid users in completing the submission.
	22-29	Beneficiary Workflow Provide Your Contact Information Point of Contact field	New - add as follows:	Add question mark help text to, “Point of Contact” field: “CMS uses your contact information to send responses and ask follow up questions.”	Added help text to aid users in completing the submission.
	22-29	Beneficiary Workflow Provide Your Contact Information Zip Code field	New - add as follows:	Add “Zip Code” field (mandatory) This field is mandatory. This field is placed below the “Last name” field and above the “Phone number” field. Add question mark help text: “Please enter your 5-digit zip code.” Add ghost text: “XXXXX”	Added Zip Code to ensure accuracy of submitter location information. Added help text to aid users in completing the submission. Added ghost text to aid users in completing the submission.
	22-29	Beneficiary Workflow Provide Your Contact Information Phone number field	New - add as follows:	Add ghost text for “Phone number” field: “(XXX)XXX-XXXX”	Added ghost text to aid users in completing the submission.
	22-29	Beneficiary Workflow Provide Your Contact Information Organization Information	New - Add as follows:	Add new section, “Organization Information” Add question mark help text: “An organization is an organized body of people with a particular purpose (e.g., State, Corporation, Health System, etc.). Please provide the required information for your organization.” Add instruction help text: “Who is the organization making this request?”	Added help text to aid users in completing the submission. Added help text to aid users in completing the submission.
	22-29	Beneficiary Workflow Provide Your Contact Information Organization Name	New - Add as follows:	Add new field, “Organization Name” This field is mandatory. This field is placed below “Organization Information” and above “Organization Categories”	This information allows the system to automatically route requests to the correct CMS respondent, thereby allowing CMS to respond more quickly to the submitter.
	22-29	Beneficiary Workflow Provide Your Contact Information Organization Categories	New – Add as follows:	Add new field, “Organization Categories” This field is mandatory. This field is placed below “Organization Name” field and above the tabbed options for selection. Add question mark help text: “This provides CMS additional information on the type of organization requesting a inquiry. Please select all applicable organizations by reviewing the data on all three tabs (At least one category must be selected).” Add instruction help text: “Who is the organization making this request?”	This information allows the system to automatically route requests to the correct CMS respondent, thereby allowing CMS to respond more quickly to the submitter.
	22-29	Beneficiary Workflow Provide Your Contact Information Organization Categories General Tab	New - Add as follows:	Add 1st tab, “General” Add the following checkboxes on this tab: Advocacy Group Association Corporation Medicare Advantage/Part D Plan State Government Qualified Health Plan State Medicaid Agency State Survey Agency Tribal Nation	This information allows the system to automatically route requests to the correct CMS respondent, thereby allowing CMS to respond more quickly to the submitter.
	22-29	Beneficiary Workflow Provide Your Contact Information Organization Categories Emergency Provider / Supplier Types tab	New - Add as follows:	Add 2nd tab, “Emergency Provider / Supplier Types” Add the following checkboxes on this tab: Ambulatory Surgical Center (ASC) Community Mental Health Center (CMHC) Comprehensive Outpatient Rehabilitation Facility (CORF) Critical Access Hospital (CAH) Community Mental Health Center (CMHC) End Stage Renal Disease (ESRD) Home Health Agencies (HHA) Hospice Hospital Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) Nursing Homes (SNF/NF) Organ Procurement Organization (OPO) Outpatient Physical Therapy/Speech Therapy (OPT/ST) Programs of All-Inclusive Care for Elderly (PACE) Psychiatric Residential Treatment Facility (PRTF) Religious Non-Medical Health Care Institution (RNCHI) Rural Health Clinic/Federally Qualified Health Center (RHC/FQHC) Transplant Center	This information allows the system to automatically route requests to the correct CMS respondent, thereby allowing CMS to respond more quickly to the submitter.
	22-29	Beneficiary Workflow Provide Your Contact Information Organization Categories Other tab	New - Add as follows:	Add 3rd tab, “Other” Add the following checkboxes on this tab: Ambulance Durable Medical Equipment (DME) Lab Other Palliative Physician Other (if selected, "Other Organization Category" input box is made visible and editable and mandatory)	This information allows the system to automatically route requests to the correct CMS respondent, thereby allowing CMS to respond more quickly to the submitter.
	22-29	Beneficiary Workflow Provide Your Contact Information Organization Identification Numbers	New - Add as follows:	Add section, “Organization Identification Numbers” Add question mark help text: “Indicate all applicable identification numbers for the healthcare facilities/providers affiliated with your organization impacted by the PHE.” Add instruction help text: “What are the identification numbers for your organization? These numbers will be different, depending on the categories you have selected for your organization including: CCN/Provider, Medicare Contract Number, or NPI. For the categories selected above, use:”	This information allows the system to automatically route requests to the correct CMS respondent, thereby allowing CMS to respond more quickly to the submitter. Added help text to aid users in completing the submission.
	22-29	Beneficiary Workflow Provide Your Contact Information Organization Identification Numbers	New - Add as follows:	Add “IDENTIFICATION NUMBER” field (not mandatory) Add ghost help text: “Separate multiple identification numbers with a comma.”	This information allows the system to automatically route requests to the correct CMS respondent, thereby allowing CMS to respond more quickly to the submitter. Added ghost text to aid users in completing the submission.
	22-29	Beneficiary Workflow Inquiry	New – Add as follows:	Allow for multiple Inquiry requests in one web form submission. Add label, “Request #1” and as each submission is made a new section opens up with the Topic, Type, and Description fields visible and editable and the subsequent request is named appropriately, “Request #2, Request #3, etc.”	Added the ability to submit multiple requests in a single submission to ease the burden on users by streamlining the submission process.
	22-29	Beneficiary Workflow Inquiry Topic	Revise as follows:	Replace “Inquiry Topic” field name with “Topic” The field is mandatory. “Topic” field values are: Medicaid/CHIP Original Medicare (Part A or B) Medicare Advantage/Prescription Drug Plan Qualified Health Plans Add question mark help text: “Choose from the dropdown list which category your inquiry would fall under.”	Simplified the field label. Added help text to aid users in completing the submission.
	22-29	Beneficiary Workflow Inquiry Type	Revise as follows:	Replace “Inquirer Type” field name with “Type” This field is mandatory. “Type” field values are: 638 Tribal Clinics Academia Access To Care Advocate Ambulance Ambulatory Care Center Appeals Appendix K Association/Society for Provider/Facility Attorney for Provider/Facility Billing Agency Consultant for Provider/Facility Critical Access Hospital Denials Dialysis Facility Eligibility Employer Facility Fair Hearings Federal/State Government Agency Federally Qualified Health Center (FQHC) General Public HCBS Waivers Home Health Hospice Hospital Insurance Company Long Term Care Services And Supports Managed Care Medical Supplier/DME Nurse/Nurse Practitioner Nursing Home Other Payment Methodology/Rates Pharmacist/Pharmacy Physical/Occupational Therapy Physician Physician Assistant Provider – Mental Health Provider - Other Provider Enrollment Respite Retainer Payments Rural Health Clinic Rural Health Clinic (RHC) Skilled Nursing Facility State Agency Telehealth The “Type” field is placed below the “Topic” field. Add question mark help text: “Choose your inquiry type from the dropdown list.” Add checkbox field, “Click here if you do not see your type” If the checkbox is true, then input box is made visible, editable, and mandatory.	Simplified the field label. Added help text to aid users in completing the submission. This checkbox was added to give users a mechanism for indicating an inquiry type not represented in the selectable options.
	22-29	Beneficiary Workflow Inquiry Description	New - Add as follows:	Add field, “Description” This field is mandatory. Add ghost help text: “Provide a comprehensive description of your inquiry (including regulation citations if applicable). Add a link for the submitter to select to open up the Topic, Type, and Description field for entry of next Inquiry request, “+ Add another inquiry request”	This information allows CMS to understand the nature of the inquiry in order to provide an accurate response. Added ghost text to aid users in completing the submission. Added a link to allow users to submit multiple requests in a single submission to ease the burden on users by streamlining the submission process.
	22-29	Beneficiary Workflow Footer: Warning message	Revise as follows:	Replace: “For detailed information regarding transmitting or receiving healthcare information or data read the QualityNet System Security Policy (PDF). With: “For detailed information regarding safeguarding protected healthcare information or data, please refer to the ""HIPAA Security Rule"" (https://www.hhs.gov/hipaa/for-professionals/index.html).	Corrected the reference to QualityNet System Security policy to the HIPAA Security Rule.

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