Waiver Flexibility Request Crosswalk

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

Issue #	Page #	Section	Action to be performed	Changes to the Application	Reason for the Change
	2	All	Added Help Tooltips	Addition of Help Tooltips throughout form	Added tooltips to aid users in completing the submission.
	2	“What would you like to do?”	Moved help text	Moved Help Text 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 to under “What would you like to do?” selectable options	Moved the help text to a more natural location.
	2	“What would you like to do?”	Update selectable options	Added selectable option I want to provide a status update on my patients and/or healthcare facility residents to “What would you like to do?”	This option was added to account for the Health Care Facility Status submission option.
	2	1	Update selectable options	Update of selectable options in ‘Public Health Emergency (PHE)’ field	What was changed? These options are available for selection only during the PHE.
	2	2	Addition of Ghost Text	Addition of acceptable format ghost text to “Phone Number” field	Added ghost text to aid users in completing the submission.
	2	2	Content update to text	Made Organization Categories field 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.
	2	2	Removal of selectable options	Removed ‘Part D prescription Plan’, ‘Congressional Office’, and ‘Department of Health and Human Services’ selectable options from the Organization Categories – General tab	Office of Legislation requested the removal of these two options.
	2	2	Content update to text	Updated content for selectable option on Organization Categories - Emergency Provider / Supplier Types tab ‘Organ Procurement Organization’ to read ‘Organ Procurement Organization (OPO)’	Users recognize the acronym “OPO”, which was added to clarify the organization.
	2	2	Removal of selectable options	Removed ‘Programs of All-Inclusive Care for Elderly (PACE)’ selectable option from the Organization Categories - Emergency Provider / Supplier Types tab	OPOLE requested the removal of this option for waiver requests.
	2	2	Addition of Field	Added “Other Organization Category” text field	This option was added to give users a mechanism for indicating an organization not represented in the selectable options.
	2	2	Addition of Ghost Text	Addition of ghost text “Separate multiple identification numbers with a comma” to “IDENTIFICATION NUMBER” field	Added ghost text to aid users in completing the submission.
	2	3	Addition of Field	Addition of Checkbox Field with label “Click here if you do not see your Waiver Request Type” and Text box	This checkbox was added to give users a mechanism for indicating a waiver request type not represented in the selectable options.
	2	3	Updated Field Label	Changed Field label from “Regulation Description” to “Request Description”	This is a correction to the field label.
	2	3	Addition of Ghost Text	Addition of ghost text to “Request Description” field: Detail a brief summary of why the waiver is needed (For example: CAH is sole community provider without reasonable transfer options at this point during the specified emergent event (e.g. flooding, tornado, fires, or flu outbreak). CAH needs a waiver to exceed its bed limit by X number of beds for Y days/weeks (be specific)) and the type of relief you are seeking.	Added ghost text to aid users in completing the submission.
	2	4	Updated content	Updated Submission Message Content to read: Thank You! Your request has been successfully submitted. Your case number is <Case#> You will also receive an email confirmation summarizing your request and providing you with additional guidance.	Reworded the confirmation message to be more professional.
	2	Footer	Updated Content	Updated Warning footer content to read: WARNING: Individually identifiable health information in this system is subject to the Health Information Portability and Accountability Act of 1996 and the Privacy Act of 1974. Submission to the 1135 Waivers System that contains Protected Health Information (PHI) is a violation of these Acts. Questions containing PHI will be deleted from the system and not processed. 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.
	2	Dropdown Lists State/US Territory/Federal District	Updated Content	Added American Samoa, Guam, and Puerto Rico to the State/US Territory/Federal District dropdown list.	Added missing US territories.