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Unpacking the Informal Review Process

Note: The process and information outlined in this post reflect the PQRS and Value-Modifier Informal Review process. We will post an article about the MIPS and new Quality Payment Program Informal Review process when it becomes available by CMS (estimated Fall 2018).

What is an Informal Review?

An informal review is a process that allows a provider or practice to request a review of their most recent CMS submission if they believe CMS made an error. Most recently, a PQRS Eligible Professional (EP) or Group was able to request a review of their 2016 PQRS submission if they feel they will be receiving a 2018 payment adjustment in error. The deadline for the PQRS 2016 Informal Review period has now passed; it was December 1, 2017.

Once the Informal Review request is submitted by the EP or Group, CMS will investigate further whether or not the submission criteria were satisfactorily reported. In many cases, EPs and Groups have a chance of seeing the payment adjustment decision reversed. CMS will notify the Informal Review requestee what the final determination is via email.

How can I file an Informal Review request?

We’ll walk you through the steps for filing an Informal Review, you can also contact us for guidance if needed.

Step 1: Identify the TIN and NPI of the EP or Group for which you will be filing the Informal Review (only a TIN is needed if filing for a Group), then navigate to the Quality Reporting Communication Support Page in your web browser.

Select “Communication Support Page”→ “Informal Review Request” → “PQRS Informal Review” from the Navigation Pane on the left side of your screen.

Step 2: Enter the TIN and NPI then press “Submit”

Step 3: Complete the mandatory fields in the online form, agree to the terms and conditions, then press “Submit”

Step 4: If completed correctly, a new page will be generated informing you that your request was accepted and it will provide a ticket number.
Important: Document your ticket number in a safe location, as you may need this to reference your request in the future. We recommend taking a screenshot of the confirmation page and saving it to your computer.

How will I know if I should submit an Informal Review?

You can obtain a copy of your 2016 PQRS Feedback Report by logging into the CMS Enterprise Portal. Once you have obtained your Feedback Report, review your PQRS Payment Adjustment Summary report, paying specific attention to the “Subject to 2018 PQRS  Payment Adjustment?” column. If this column is marked “Yes” for any provider in your summary, they will be subject to the 2018 PQRS Payment Adjustment.

You can also use the CMS PQRS Lookup Function to enter the TIN and NPI to determine if they are receiving a penalty.

Don’t Forget About the Value Modifier Informal Review

An EP or Group is subject to the automatic downward adjustment from the 2018 Value Modifier if they did not avoid the 2018 PQRS Payment Adjustment. You can determine if you are receiving a value-modifier penalty by reviewing your QRUR which you can also download from the CMS Enterprise Portal. Again, if you believe there is an error in CMS’ determination, you will need to file a Value Modifier Informal Review request in addition to your PQRS Informal Review Request.

The Value Modifier Informal Review is completed in a similar manner as the PQRS Informal Review. The Value Modifier Informal Review link is located just below the PQRS Informal Review link in the Communication Support Page Navigation Pane.

Mingle Health is here to help

Mingle Health is experienced in Medicare quality reporting and we have the knowledge and resources to ensure your Informal Review requests will be processed correctly. One of the benefits to being a Mingle Health client is the expert support from your Quality Reporting Consultant.

With a proven track record for getting payment adjustments reversed through CMS, our Consultants are prepared to help you navigate the ins-and-outs of the entire Informal Review process. Contact us today for assistance and to find out how MIPS Solutions by Mingle Health can help you succeed in the new Medicare Quality Payment Program.


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