CMS-10250.OQR_With CMS-10250.OQR_Withdraw Form

Withdraw Notice of Participation

Hospital Outpatient Quality Reporting Program Notice of Participation *Indicates Required Field

Medicare-certified hospitals that provide hospital outpatient services can participate in the Hospital Outpatient Quality Reporting Program. This quality reporting program seeks to increase transparency and quality of care for services delivered in the hospital outpatient setting through the collection and public reporting of quality of care information.

Hospitals defined under section 1886(d)(1)(B) of the Social Security Act, known colloquially as "sub-section (d)" hospitals that are paid under the Outpatient Prospective Payment System (OPPS) are required to meet Hospital Outpatient Quality Reporting Program requirements or such hospitals may receive a reduction in their Medicare Annual Payment Update (APU) for the applicable Calendar Year.

Hospitals that are not classified as "sub-section(d)" hospitals (e.g. Critical Access and other non-PPS hospitals), or are sub-section (d) hospitals not paid under the OPPS (e.g. Indian Health Services hospitals) may participate in the Hospital Outpatient Quality Reporting Program, but their Medicare payment is not at risk.

For a hospital to be deemed as participating, a hospital need only submit and have accepted any quality data collected under the Hospital Outpatient Quality Reporting Program. However, if a hospital is participating and wants to withdraw, an acknowledgement of a request to withdraw is required.

Any participation or withdrawal from participation applies to all entities reimbursed under a provider’s payment identifier, the CMS Certification Number (CCN).

We entities operating under the submitted Provider ID request to be withdrawn from the previous pledge. *

Notes

This notice acknowledges that this hospital is withdrawing from participation in this program.

This withdrawal will remain in effect until program data are submitted electronically and accepted.

*For Paperwork Reduction Act Notice, see Specification Manual

This acknowledgement (to participate or to withdraw) remains in effect until an electronically signed acknowledgement applying changes has been entered.

By entering my acknowledgement, I hereby issue this OQR Notice of Participation with the specified direction contained within. *