Skilled Nursing Facility (SNF) 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 SNF QRP. You will also find guidelines for submitting reconsideration requests and requests for exceptions and exemptions.

SNF QRP: Natural Disaster Protocol

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

Updates

Reconsideration

Reconsideration Request Overview

In the Fiscal Year (FY) 2016 Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Final Rule (80 FR 46459 through 46461), the Centers for Medicare & Medicaid Services (CMS) finalized the process for submitting SNF Quality Reporting Program (QRP) reconsideration requests and requests for exceptions and exemptions. The process was updated in the FY 2019 SNF PPS Final Rule (83 FR 39270 through 39271). Any SNF determined to be non-compliant with the SNF QRP requirements may be subject to a two percentage (2%) point reduction in their Annual Payment Update (APU) beginning FY 2018 and each subsequent rate year.

Any SNF 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 SNF 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 SNFs MAC.

This letter also includes the reason(s) for failing APU 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 SNF, for a given FY.

When Would a SNF Submit a Reconsideration Request?

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

Important Note: Any exception or extension requests submitted for purposes of the SNF QRP will apply to that program only, and not to any other program CMS administers for SNFs, such as survey and certification. Exceptions related to Minimum Data Set (MDS) requirements during Declared Public Health Emergencies, including electronic submission, can be found in the Frequently Asked Questions (FAQs), Declared Public Health Emergencies – All Hazards FAQs (PDF), specifically K-5, K-6 and K-9.

Reconsideration Request Process

To apply for reconsideration, the SNF must receive a CMS letter of non-compliance. A SNF 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) days 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.

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

The email request must contain the following information:

• SNF CCN
• SNF Business Name
• SNF Business Address
• CEO or CEO-designated personnel contact information including name, telephone number, email address, 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 SNF’s 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 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 resident-level data or PHI/PII may be a violation of your facilities’ policies and procedures as well as violation of federal regulations (that is, HIPAA).

Any documentation submitted for review that includes PHI or PII will not be accepted, nor 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 SNF QRP Data Submission Deadlines webpage for information on data collection timeframes and submission deadlines.

Reconsideration Request Process Timeline

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

• June - July: CMS issues notices of non-compliance to SNFs 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 SNFQRPReconsiderations@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: SNFs are notified of the agency’s decision on the reconsideration requests via letter from the MACs and CMS.
• October: Annual Payment Update (APU) penalty will be imposed on all providers found to be non-compliant with quality reporting requirements.

Filing an Appeal

Skilled Nursing Facilities (SNFs) 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 website. 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 Skilled Nursing Facilities (SNFs) 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. SNFs affected by a natural or man-made disaster or other extraordinary circumstances may request an exception or extension by filing a Request for Reconsideration Due to Disaster or Extraordinary Circumstance.

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

All SNFs 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 or extension to SNFs 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.

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

• SNF CMS Certification Number (CCN)
• SNF Business Name
• SNF 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 or extension
• A date when the SNF believes that it will again be able to submit SNF QRP data and a justification for the proposed date
• Any other documentation supporting the rationale for seeking reconsideration

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, SNFs may submit questions related to the reconsideration or exception and extension request to SNFQRPReconsiderations@cms.hhs.gov.

SNF Quality Reporting Program Archives