Form CMS-10520 Vendor Appeal Form

Marketplace Quality Standards (CMS-10520)

CMS-10520 - QHP Survey - Request for Appeal Form

Monitoring and appeals process for survey vendors

OMB: 0938-1249

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OMB No. 0938-1249: Approval Expires XX/XX/XXXX


Qualified Health Plan Enrollee Experience Survey

2020 Request for Appeal Form


Organization Name:



Date Submitted:



Address:



Primary Contact:



Title:



Telephone:



Email:



Please provide new or additional information in the response section(s) below for each Criterion Not Met that is being appealed and a justification for the initial exclusion of this information from your organization’s 2020 QHP Enrollee Survey Vendor Participation Form.


Criterion Not Met:



New or Additional Information:



Justification for Exclusion from Vendor Participation Form:




Criterion Not Met:



New or Additional Information:



Justification for Exclusion from Participation Form:




Submit the appeal form to the Project Team via email at the following address: [email protected]. Please include the following in the subject line: “[Vendor Name] 2020 Vendor Appeal Form”.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1249. The time required to complete this information collection is estimated to average 2 hours per response. 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.

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleQHP Survey Monthly Progress Report: June 2017
SubjectQuality Health Plan Survey Progress Report
AuthorBooz Allen Hamilton
File Modified0000-00-00
File Created2022-06-16

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