Home Health Quality Reporting Reconsideration and Exception & Extension

The Reconsideration Requests webpage provides information and updates related to the reconsideration process for the Home Health Quality Reporting Program (HH QRP). On this page, you will find guidelines and processes for submitting reconsideration requests and requests for exceptions and extensions, effective date 1/1/2018. For questions related to the content posted on this page, contact the Centers for Medicare & Medicaid Services (CMS) HH APU Reconsiderations Team at HHAPUReconsiderations@cms.hhs.gov.

Updates

What is Reconsideration?

Reconsideration is a request for a review of the initial CMS compliance determination for a given Home Health Agency (HHA) for a given calendar year (CY).

When Would an HHA Submit a Reconsideration Request?

HHAs may file for reconsideration if they believe the CMS findings of non-compliance are in error, or if they have evidence of the impact of extraordinary circumstances which prevented timely submission of data. HHAs will have 30 days from the date at the top of the letter of noncompliance to submit this request for reconsideration to CMS.

Note: A request for reconsideration due to a deficiency in the Home Health reporting of data as required in the Home Health QRP due to a disaster is separate and aside from the waiver requirements and purposes pursuant to 42 CFR §484.250(d).

Reconsideration Request Process

To apply for reconsideration, the HHA must receive a CMS letter of non-compliance. An HHA disagreeing with the payment reduction decision may submit a request for reconsideration to CMS within thirty (30) days from the date at the top of the non-compliance notification letter. CMS will not accept any requests submitted after the thirty (30) days deadline.

Create a Reconsideration Request

Note: The only method for submitting reconsideration requests is by email. Requests submitted by any other means will not be reviewed for reconsideration.

HHAs are required to submit their request to CMS via email with the subject line: “HHA QRP Reconsideration Request” and include the HHA CMS Certification Number (CCN) (e.g., HHA QRP Reconsideration Request, XXXXXX). The request must be sent to the following email address HHAPUreconsiderations@CMS.hhs.gov

The email request must include the following information:

• The email request must contain the following information:
  • HHA CMS Certification Number (CCN)
  • HHA Business Name
  • HHA Business Address
  • CEO or CEO-designated personnel contact information including name, telephone number, email address, and mailing address (the address must be a physical address, not a post office box); and
  • CMS identified reason(s) for non-compliance from the non-compliance notification letter; and
  • Information supporting the HHA belief that either non-compliance is in error, or evidence of the impact of extraordinary circumstances which prevented timely submission of data

The request for reconsideration must be accompanied by supporting documentation demonstrating compliance. CMS will be unable to review any request that fails to provide the necessary documentation, nor accept any files that are larger than 20 MB (megabytes). Supporting documentation may include any or all of the following:

• Proof of submission
• Email communications
• Data submission reports from the Internet Quality Improvement Evaluation System (iQIES)
• Proof of previous waiver approvals (including disaster exceptions/exemptions)
• Copy of the CCN activation letter
• Other documentation supporting the rationale for seeking reconsideration

IMPORTANT:

Never include patient information (i.e., protected health information [PHI], patient identifiable information [PII], or other Health Insurance Portability and Accountability Act [HIPAA] data) in the documentation being submitted to CMS for review. Submitting patient-level data or PHI/PII may be a violation of your facilities’ policies and procedures as well as a violation of federal regulations (that is, HIPAA). 

Any documentation submitted for review that includes PHI or PII will not be accepted or reviewed for reconsideration. Please redact any PHI/PII prior to sending. If any documents included in a reconsideration request contain PHI/PII, the entire request will be rejected. 

Reconsideration Request Process Timeline

Below is the estimated CMS reconsideration process timeline for CY Annual Payment Update determination:

• Late September/Early October - CMS issues notices of non-compliance to HHAs that failed to meet quality reporting requirements
• Late October/Early November - Reconsideration requests are due to CMS no later than thirty (30) days from the date on the notification of non-compliance
• CMS provides an email acknowledgment within five (5) business days upon receipt of the reconsideration request.
• Mid December - CMS notifies HHAs of the Agency's decision on the reconsideration requests via a letter from the MACs and/or from the reconsideration review contractor via USPS or another trackable method.

Filing an Appeal

HHAs dissatisfied with the reconsideration ruling may file a claim under 42 CFR Part 405, Subpart R (a Provider Reimbursement Review Board [PRRB] appeal). Details are available on the CMS.gov PRRB Review Instructions webpage. You must follow the instructions listed on that website to file with the PRRB.

If the amount in controversy is at least $1,000, but less than $10,000, then Federal Specialized Services (“FSS”) will manage the dispute as an Intermediary Hearing. Requests for an Intermediary Hearing should be sent electronically to intermediary@fssappeals.com.

Extraordinary Circumstances: Exception and Extension

Exception and Extension Requests Overview

CMS provides HHAs an opportunity to request an exception or extension from the program’s reporting requirements in the event they are unable to submit quality data due to extraordinary circumstances beyond their control. HHAs affected by a natural or human-caused disaster or other extraordinary circumstances may request an exception or extension by filing a Request for Reconsideration Due to Disaster or Extraordinary Circumstance.

Note: A request for reconsideration due to a deficiency in the Home Health reporting of data as required in the Home Health QRP due to a disaster is separate and aside from the waiver requirements and purposes pursuant to 42 CFR §484.250(d).

Definitions

• Extraordinary Circumstances: Natural or human-caused disasters preventing the timely submission of quality data. A disaster may be widespread or affect multiple structures or isolated and affect a single site only.
• Extension: Submission deadline extended. CMS can extend submission deadlines for the specified deadlines for 30 to 45 days beyond the scheduled due date applicable to other facilities.
• Exception: Submission deadline waived. CMS can exempt a facility from submitting quality data for the specified deadlines without impacting the Annual Payment Update.

When an extension/exception is granted, an HHA will not incur payment reduction penalties for failure to comply with the requirements of the HH QRP. Under the finalized process, an HHA may request an extension/exception of the requirement to submit quality data for a specified time period by submitting a written request to CMS.

This process does not preclude CMS from granting extensions/exceptions to HHAs for not requesting an extension/exception when an extraordinary circumstance, such as an act of nature, affects an entire region or locale. When an extension/exception to HHAs in a region or locale is granted, CMS will communicate the decision through routine channels to HHAs and vendors, including, but not limited to the PAC QRP listserv, Open Door Forum MLN Connects, PAC, and notices on the CMS Home Health Quality Reporting Spotlight webpage.

Submission Exception and Extension Process in Cases of Disaster or Extraordinary Circumstances

Here are the key elements of an exception or extension request:

• All HHAs requesting an exception or extension must submit the request within ninety (90) days of the event. CMS may grant the exception or extension for one or more quarters.
• HHAs must request an exception or extension via email with the subject line, “HH QRP Exception or Extension Request”
• The exception or extension request must be sent to: HHAPUReconsiderations@cms.hhs.gov.

The email must also include all of the following information:

• HHA CCN
• HHA business name
• HHA Business Address
• CEO or CEO-designated personnel contact information including name, telephone number, email address, and mailing address (the address must be a physical address, not a post office box)
• Evidence of the impact of extraordinary circumstances, including, but not limited to, photographs, newspapers, and other media articles.
• A date when the HHA believes it will be able to again submit HH QRP data and a justification for the proposed date.
• Any other documentation supporting the rationale for seeking reconsideration
• If you do not have all of the documentation, explain it in your request.

Note: Never include PHI or other HIPAA violations in the documentation being submitted to CMS for review. CMS will not review requests that include PHI or any data violating HIPAA.

Important Note: Any exception or extension requests submitted for purposes of the HH QRP will apply to that program only, and not to any other program CMS administers for HHAs, such as surveys and certification.

Response from CMS

CMS will provide a written acknowledgment upon receipt of the exception and extension request. CMS will notify the CEO or CEO-designated contact provided in the request of the decision, via United States Postal Service (USPS) mail and email.

For More Information

For additional assistance, HHAs may submit questions related to the HH QRP exception and extension request to: HHAPUReconsiderations@cms.hhs.gov.

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