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Request for Reconsideration
ICR 202611-0938-006 · OMB 0938-1129 · Object 174840100.
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Document Metadata
| File Type | application/pdf |
|---|---|
| File Title | Request for Reconsideration |
| Author | Centers for Medicare & Medicaid |
| Last Modified By | Microsoft® Word for Microsoft 365 |
| File Modified | 2026-08-03 |
| File Created | 2026-08-03 |
| Conversion State | complete |
Extracted Text
Request for Reconsideration Note: The QBP administrative review process is a two-step process that includes: 1) a request for reconsideration, and 2) a request for an informal hearing after CMS has rendered its reconsideration decision. Both steps are conducted at the contract level. This first step affords an MA organization the opportunity to request a reconsideration of how its Star Rating, for the given measure in question, was calculated. This is not an opportunity for an MA organization to question how every measure was calculated. A request for reconsideration must be submitted by the date and time specified below in order to reserve the right to later request an informal hearing on the record. Instructions: Use only the “Request for Reconsideration” form that can be found in HPMS. To download a copy of the form from HPMS, select Quality and Performance on the home page, then Performance Metrics. On the Performance Metrics page select Reports, Costs and then MA QBP Rating. One form must be submitted for each contract for which reconsideration is requested. Complete the identifiable information including all contact information. Mark an “X” next to the measure(s) that the MA organization is questioning and requesting reconsideration. In the “Description of the Issue” specify any errors that the MA organization asserts CMS may have made in calculating the contract's QBP determination. Save the information, please include your contract number in the filename and e-mail the completed form along with any additional documentary evidence to be considered to [email protected] by the due date. Due Date: A Request for Reconsideration of QBP is made by completing the Excel version of this form downloaded from HPMS and e-mailing the form to [email protected] by 5:00 p.m. EST on XXXXX. No late requests will be accepted. Contract Number (5 character CMS assigned code): Contact First Name (your first name): Contact Last Name (your last name): Contact Title (your job title): Contact Phone Number (your phone number, include extension if necessary): Contact email address (your email address): Overall Rating Data Source Miscalculation Incorrect Data Description of the Issue (Please enter as much text as necessary to describe the reason you believe there was a Miscalculation and/or that Incorrect data were used) QBP/Overall Rating Part C Measures C01 C02 C03 C04 C05 C06 C07 C08 C09 C10 C11 C12 C13 C14 C15 C16 C17 C18 Data Source Miscalculation Incorrect Data Description of the Issue (Please enter as much text as necessary to describe the reason you believe there was a Miscalculation and/or that Incorrect data were used) Data Source Part C Measures Miscalculation Incorrect Data Description of the Issue (Please enter as much text as necessary to describe the reason you believe there was a Miscalculation and/or that Incorrect data were used) C19 C20 C21 C22 C23 C24 C25 C26 C27 C28 C29 C30 C31 C32 Part D Measures D01 D02 D03 D04 D05 Data Source Miscalculation Incorrect Data Description of the Issue (Please enter as much text as necessary to describe the reason you believe there was a Miscalculation and/or that Incorrect data were used) Part D Measures Data Source Miscalculation Incorrect Data Description of the Issue (Please enter as much text as necessary to describe the reason you believe there was a Miscalculation and/or that Incorrect data were used) D06 D07 D08 D09 D10 D11 D12 D13 Additional Comments (Please provide any additional information relevant to your request): 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 0938-1129 and form number CMS-10346 (Expires: XXXX). The time required to complete this information collection is estimated to average 8 hours, 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 C1-25-05, Baltimore, Maryland 21244-1850.