CMS-10210 IQR Reconsideration Request Form

CMS Quality Reporting Program
APU Reconsideration Request Form
When the Centers for Medicare & Medicaid Services (CMS) determines that a facility did not
meet the Quality Reporting Program requirement(s) for the Annual Payment Update (APU), the
facility may submit a request for reconsideration to CMS by the deadline identified on the APU
Notification Letter.
Once this form has been completed, please submit via Managed File Transfer to
[email protected], via secure fax to 877-789-4443, or email
[email protected].
Following the receipt of the request form, an email acknowledgement will be sent confirming the
form has been received. Once a determination has been made, CMS will provide the formal
decision regarding the reconsideration request.
*Indicates required field

*Facility Information:
*Program Requesting Reconsideration: __ Inpatient __ Psych __ Outpatient __ Ambulatory
Surgical Center (ASC)
*Date of Request (MM/DD/YYYY): ____/____/_____
*CMS Certification Number (CCN) (Not required for ASC): __________________
*National Provider Identification (NPI) (Required for ASC only): ________________________
*Facility Name: _______________________________________________________________

*CEO Contact Information (Required for Inpatient and Psych) or
Designated Contact Information (Required for Outpatient and ASC):
Please ensure within your organization that U.S. Mail and deliveries from overnight services
directed to this address will reach the necessary party.
*Name and Title: ______________________________________________________________
*Email Address: ______________________________________________________________
*Telephone Number: ______-______-_______ Ext. __________
*Mailing Address (must include physical address; P.O. Box addresses are not valid):
____________________________________________________________________________
*City: ________________________________________________________________________
*State: ____

*ZIP Code: __________-_______

*Security Official Contact Information (Not required for ASC):
*Name and Title: ______________________________________________________________
*Email Address: ______________________________________________________________
*Telephone Number: ______-______-_______ Ext. __________
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CMS Quality Reporting Program
APU Reconsideration Request Form
*Mailing Address (must include physical street address; P.O. Box addresses are not valid):
____________________________________________________________________________
*City: _______________________________________________________________________
*State: ____

*ZIP Code: __________-_______

*Reconsideration Request Information:
*CMS-Identified Reason Facility Did Not Meet the APU Requirements: These details were
provided in the formal CMS APU Notification Letter that was sent to your CEO/Designee.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

*Reason for Reconsideration Request: Please state your facility’s reason for requesting
reconsideration. This must identify the specific reason(s) for believing your facility did meet the
Quality Reporting Program requirements and should receive the full APU. Please Note: A
facility must submit all documentation and evidence that supports its request for reconsideration
at the time that it submits its request. This includes copies of any communications, such as
emails that the facility believes demonstrate its compliance with the program requirements.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Additional Comments:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

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CMS Quality Reporting Program
APU Reconsideration Request Form
Validation Review for Reconsideration Request Information:
Was one of your reasons for not meeting the annual requirement(s) related to Validation?
If Yes, PLEASE NOTE: Requests related to validation element mismatches for the clinical
process measures may require additional facility actions.
Electronic Clinical Quality Measure (eCQM) Validation:
No further actions are required.
Chart-Abstracted Validation:
In addition to filing the Reconsideration Request Form as outlined above, facilities must also
complete a Validation Review for Reconsideration Request Form (available on the QualityNet
website) which includes fields to provide written justification for each mismatched case that you
wish to appeal. Facilities may also include medical records for appealed cases, if applicable.
Additional information/instructions on how to submit the form and medical records to the
Validation Support Contractor can be found on the Validation Review for Reconsideration
Request Form. The Validation Review for Reconsideration Request Form and any medical
records (if applicable) must be received by the deadline identified on the APU
Notification Letter. CMS will review the data elements that were labeled as mismatched, as
well as the written justifications provided by the facility, and make a decision on the validation
reconsideration request.

SIGNATURE
*CEO/Designated Personnel Signature__________________________
Date _____/____/____
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
XX/XX/XXXX). 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, MD 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
Inpatient Value, Incentives, and Quality Reporting Outreach and Education Support Contractor at (844) 472-4477.

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