Form CMS-10495 Review and Dispute Screen Shots

OMB Control No: 0938-1237
Expiration Date: XX/20XX

Screen Shots – Review & Dispute
The screen shots below illustrate the Review & Dispute process for the Open Payments system:

Select Review & Dispute where the yellow arrow is below:

OMB Control No: 0938-1237
Expiration Date: XX/20XX
Select your name and program year you wish to view:

OMB Control No: 0938-1237
Expiration Date: XX/20XX
Then review your records, and use the check box to either “Affirm Record” or “Dispute Record”:

OMB Control No: 0938-1237
Expiration Date: XX/20XX
Then enter the reason for your dispute and hit “Send Dispute”

OMB Control No: 0938-1237
Expiration Date: XX/20XX
This is what you will see when your dispute has been confirmed

Now the entity will go back into their review and dispute page and can either edit or delete the record.
If the record is modified you can repeat the above process to verify the changes or re-dispute the
record.