Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

Requesting an Informal Review of Your 2015/2017 PQRS Determination

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When the Centers for Medicare and Medicaid Services (CMS) releases PQRS Feedback Reports in the next few weeks, providers who believe a 2017 negative PQRS payment adjustment was applied incorrectly can request an informal review.

An informal review allows individual EPs, Comprehensive Primary Care practice sites, PQRS group practices, or Accountable Care Organizations to request a review of their payment adjustment determination. Once the review is requested, CMS will investigate whether the outcome was appropriate. If not, and CMS determines that satisfactory reporting was achieved, then the negative PQRS payment adjustment will be reversed.

A few things to note when you submit your request for an informal review:

  • For eligible providers who participate in PQRS as individuals, the provider or a member of their support staff should submit a review request for each TIN/NPI combination for which 2015 PQRS data was submitted. If a provider is questioning the PQRS determination for work done under multiple TINs, then an informal review request must be submitted for each TIN.
  • Group practices reporting via PQRS GPRO or ACO will request an informal review through their point of contact for the PQRS group practice TIN or each individual ACO participant TIN under which 2015 PQRS data was submitted.
  • 2015 PQRS informal review requests can be submitted through the Quality Reporting Communication Support Page. To submit the request, select “Communication Support Page” under “Related Links” in the upper left navigation pane. Then, in the drop-down menu, select “Informal Review Request” and choose the appropriate option. The page is not currently active and will not be until after the 2015/2017 PQRS Feedback Reports are released.
  • Informal review requests for 2015 reporting results may be submitted in the fall of 2016. Once the PQRS Feedback Reports are released, eligible providers will have a short window to submit the request so that CMS can render a final decision prior to the application of the payment adjustment.
  • An informal review decision is final, and there are no further opportunities for review or appeal.

For more information about requesting an informal review of your 2015/2017 PQRS determination, review the slides from a recent MLN Connects National Provider Call or visit the CMS PQRS Payment Adjustment Information webpage.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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