Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Reconsideration and Exception & Extension

This webpage provides information and updates related to the reconsideration and exception and extension process for the IRF QRP. You will also find guidelines for submitting reconsideration requests and requests for exceptions and extensions.

IRF QRP: Natural Disaster Protocol

For disasters impacting the Post-Acute Care (PAC) QRPs, a disaster-specific memo will be posted to the Downloads section on this webpage with additional information, including impacted counties and quality reporting quarters.

Updates

Reconsideration

Reconsideration Request Overview

In the Fiscal Year (FY) 2017 Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) Final Rule (81 FR 52125), the Centers for Medicare & Medicaid Services (CMS) clarified that in order to notify IRFs found to be non-compliant with the reporting requirements set forth for a given payment determination, the Quality Improvement and Evaluation System (QIES) mechanism would be an additional method to administer such notifications. In the FY 2019 IRF PPS Final Rule (83 FR 38561 through 38562), CMS expanded the methods by which IRFs would be notified of non-compliance with the IRF QRP requirements for a program year. Any IRF determined to be non-compliant with the IRF QRP requirements may be subject to a two percentage (2%) point reduction in their Annual Increase Factor (AIF).

Any IRF determined to be non-compliant according to the quality reporting requirements will receive a letter of notification from their Medicare Administrative Contractor (MAC), which will include instructions for requesting reconsideration of this decision. All Medicare-certified IRF compliance letters will be distributed through at least one of the following notification methods: the Non-Compliance Notification folders within the Internet Quality Improvement and Evaluation System (iQIES), the United States Postal Service (USPS), or via an e-mail from the IRF’s MAC.

This letter also includes the reason(s) for failing AIF compliance. News and updates may be found on the Quality Improvement and Evaluation System (QIES) Technical Support Office (QTSO) webpage. Providers will be notified regarding the specific method of communication through an announcement on this webpage posted annually following the May 15^th data submission deadline and prior to the distribution of the initial notices of non-compliance determination in late spring/early summer. Messaging will include the method of communication for the notices, instructions for sending a reconsideration request, and the final deadline for submitting the request.

What is Reconsideration?

Reconsideration is a request for a review of the initial CMS compliance determination for a given IRF, for a given FY.

When Would an IRF Submit a Reconsideration Request?

IRFs may file for reconsideration if they believe the finding of non-compliance is an error, or they have evidence of the impact of extraordinary circumstances that prevented timely submission of data.

Important Note: A request for reconsideration due to a deficiency in the IRF reporting of data as required in the IRF QRP due to a disaster is separate and aside from the waiver requirements and purposes pursuant to 42 CFR §412.614.

Reconsideration Request Process

To apply for reconsideration, the IRF must receive a CMS letter of non-compliance. An IRF disagreeing with the compliance determination and the impending 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) day deadline.

Create a Reconsideration Request

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

IRFs are required to submit their request to CMS via email with the subject line: IRF ACA 3004 Reconsideration Request and include the IRF CMS Certification Number (CCN) e.g., IRF ACA 3004 Reconsideration Request, XXXXXX). The request must be sent to the following email address: IRFQRPReconsiderations@cms.hhs.gov.

The email request must contain the following information:

• IRF CCN
• IRF Business Name
• IRF Business Address
• CEO or CEO-designated representative contact information, including name, email address, telephone number, and physical mailing address, i.e. not a post office box
• CMS identified reason(s) for non-compliance from the non-compliance notification letter
• Information supporting the IRF belief that the non-compliance finding is an error, or evidence of the impact of extraordinary circumstances that prevented timely submission of data

The request for reconsideration must be accompanied by supporting documentation demonstrating compliance. CMS will not review requests that fail 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 iQIES
• Data submission reports from the National Healthcare Safety Network (NHSN)
• Proof of previous waiver approvals (including disaster exceptions/exemptions)
• Notification of the CCN activation letter to prove that the CCN was not activated by the end of the reporting quarter
• 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 the Centers for Medicare & Medicaid Services (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 of the documents included in a reconsideration request contain PHI/PII, the entire request will be rejected.

Review Data Submission Requirements

Please refer to the IRF Quality Reporting Data Submission Deadlines webpage for more information about data submission requirements.

Reconsideration Request Process Timeline

Below is the estimated reconsideration process timeline for a fiscal year's payment determination:

• June — July: CMS issues notices of non-compliance to IRFs that failed to meet quality reporting requirements via a letter sent using at least one of the following methods:
  • The Internet Quality Improvement and Evaluation System (iQIES)
  • The United States Postal Service (USPS)
  • The Medicare Administrative Contractor (MAC)
• July — August: Reconsideration requests are due to CMS by the date indicated on the notification of non-compliance from CMS.
• July — August: CMS provides an email acknowledgment within five (5) business days upon receipt of reconsideration request.
  • Please Note: The IRFQRPReconsiderations@cms.hhs.gov email account will send an auto-reply upon receipt of your email. This email auto-reply is not the CMS acknowledgment of receipt. If you do not receive a follow-up acknowledgment of receipt within five (5) business days, please resubmit your request.
• September: IRFs are notified of the agency’s decision on the reconsideration requests via letter from the MACs and CMS.
• October: Annual Increase Factor (AIF) penalty will be imposed on all providers found to be noncompliant with quality reporting requirements.

Filing an Appeal

Inpatient Rehabilitation Facilities (IRFs) 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 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.

Exception and Extension

Exception and Extension Requests Overview

The Centers for Medicare & Medicaid Services (CMS) provides Inpatient Rehabilitation Facilities (IRFs) an opportunity to request an exception or extension from the program’s reporting requirements in the event they were unable to submit quality data due to extraordinary circumstances beyond their control. IRFs affected by a natural or man-made disaster or other extraordinary circumstances may request an exception and extension by filing a Request for Reconsideration Due to Disaster or Extraordinary Circumstance.

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

All IRFs 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. CMS may also grant the exception and extension to IRFs that have not requested one when an extraordinary circumstance, such as an act of nature, affects an entire region or locale. CMS will communicate through routine channels when such determination is made.

IRFs must request an exception or extension via email with the subject line, Disaster Exception or Extension Request” and send it to IRFQRPReconsiderations@cms.hhs.gov. The email must include the following information: 

• IRF CMS Certification Number (CCN)
• IRF Business Name
• IRF Business Address
• CEO or CEO-designated personnel contact information including name, email address, telephone number, and physical mailing address, i.e. not a post office box
• Description of the event (examples provided above) associated with the reason for requesting the exception and extension
• A date when the IRF believes that it will again be able to submit IRF QRP data and a justification for the proposed date
• Any other documentation supporting the rationale for seeking the exception and extension

Response from CMS

CMS will provide an email acknowledgment upon receipt of the exception and extension request. CMS will notify the CEO or CEO-designated contact provided in the request with the decision via email.

For More Information

For additional assistance, IRFs may submit questions related to the reconsideration or exception and extension request to IRFQRPReconsiderations@cms.hhs.gov.

IRF Quality Reporting Program Archives