What to Do After a CMS Rejection: Interpreting Feedback & Resubmission Strategy

Getting a rejection from CMS can feel like hitting a wall, especially after you’ve put in the work to submit your MIPS data. But a rejection doesn’t mean you’re out of options. Understanding what went wrong and knowing how to fix it can turn that rejection into an approval. The key is interpreting the feedback correctly and building a solid resubmission strategy.

Key Takeaways

CMS rejections typically stem from data formatting errors, TIN/NPI mismatches, incomplete submissions, or missing required documentation.
The CMS submission window is typically open for 3 months, so if your first submission is rejected or returns with errors you were not anticipating, you can continue to resubmit until the window closes and the new/update data will overwrite your previous submission.
Once the submission window closes, if your submission still had issues or rejections, the targeted review process gives you 60 days after final scores are released to request CMS review your calculations if you believe there’s still an error.
Multiple submissions from the same organization result in only the most recent submission being scored, which overrides prior submissions of the same type.
Data validation audits can occur from October through April following a performance year, requiring substantive primary source documentation within 45 days.
Success in resubmission depends on identifying the specific issue type, gathering complete supporting documentation, and submitting through the correct reporting level.

Understanding Why CMS Rejections/Errors Happen

A claim rejection occurs before processing due to errors in data entry, formatting, or patient information. In the MIPS world, rejections can stop your submission from being scored entirely. Common reasons include submitting data under the wrong Tax Identification Number (TIN) or National Provider Identifier (NPI), failing to meet data completeness requirements, or having formatting issues that prevent CMS systems from reading your submission properly.

The CMS Quality Payment Program (QPP) requires specific technical standards for all submissions. If your data doesn’t match these standards, it won’t make it through the initial screening. This is different from receiving a low score. Your submission literally doesn’t get processed.

Reading Your Performance Feedback

The final performance feedback reflects all data submitted or calculated for an individual clinician, group, or APM Entity participating in MIPS. This feedback shows your final scores and payment adjustment information. When you log into your QPP account, you’ll see breakdowns by performance category.

What to Look For

Category scores marked as “N/A” or showing zero points when you know you submitted data are red flags. Your feedback will also show whether you qualified for denominator reductions or if your submission was complete according to the 75% data completeness threshold.

To receive a valid score for Promoting Interoperability starting in the 2024 performance year, submissions must include four components: performance data, all required attestations, a CMS EHR Certification ID, and the specific performance period dates. If any of these are missing, CMS won’t score the data, not because the provider underperformed, but because the submission is considered incomplete.

Doctor using tablet

The Targeted Review Process

If you believe CMS made an error in calculating your score or payment adjustment, you can request a targeted review. The request window opens when CMS releases final scores and stays open for 30 days after publication of payment adjustment factors.

The targeted review isn’t a second chance to submit better data. It’s specifically for calculation errors made by CMS. Think of it as an appeal process where you’re asking CMS to double-check their math.

Accepted Reasons for Requesting a Targeted Review

Submitting data under an incorrect TIN or NPI
Documented eligibility or special status discrepancies
Performance categories not reweighted despite qualifying for reweighting due to extreme or uncontrollable circumstances
Submitting all valid measures but not receiving the expected denominator reduction

Related: MIPS Data Completeness

How to Submit a Successful Targeted Review

Timing matters. You have a 60-day window after CMS releases your final scores. Missing this deadline means you’re stuck with whatever adjustment you received, positive or negative.

Step-by-Step Process

Log into your QPP account Use your HCQIS Access Roles and Profile (HARP) credentials, the same ones you use for MIPS data submission.
Navigate to Targeted Review Select the option from the left-hand navigation menu. Review the list of valid and invalid reasons to make sure your situation qualifies.
Select your application type Choose Individual, Group, APM entity, or Virtual Group based on how you submitted your data originally. This needs to match your submission level exactly.
Document your issue Select the affected performance categories and provide a detailed explanation. Include any QPP service desk ticket numbers if you contacted support about this issue during the submission period.
Attach supporting documentation This is where your case gets made. Primary source documents like medical records, claims data, or screenshots showing the error can strengthen your review request.

Understanding Data Validation Audits

Separate from targeted reviews, CMS conducts data validation audits randomly. If selected, you’ll receive an email from an external audit company between October and April following the performance year. The email will come from a specific domain, so add it to your contacts and check your spam folder regularly.

You’ll have 45 days to provide substantive, primary source documents. This isn’t negotiable. Failure to comply can result in payment adjustments and increase your chances of being selected for future audits. Even if you used a third-party intermediary for submission, you’re still responsible for providing all requested documentation.

medical reports desk

What Happens During Multiple Submissions

Here’s something that trips up a lot of practices. If you submit MIPS data multiple times from the same organization, CMS only scores your most recent submission. This means your last submission overrides any prior submissions of the same type.

However, different submission types from the same organization get treated separately. If your practice reports traditional MIPS at the group level and you also report an MVP as an individual, CMS assigns the highest score that could be attributed to you under that TIN/NPI combination.

Preparing for Potential Issues

Prevention beats correction every time. Before you even submit, verify your contact information in the HARP system is current. Make sure your security official’s email is up to date since that’s where audit notifications will land.

Keep detailed records of everything you submit. Documentation must be retained for 6 years from the end of the MIPS performance period, whether or not you get audited. This includes copies of claims, medical records for applicable patients, and other resources used in your data calculations.

The MIPS cost category weight and scoring can shift between performance years, so staying current on the latest rules helps you avoid submitting outdated information.

When to Seek Professional Help

A CMS audit or complex rejection scenario might require specialized support. Medicare and Medicaid claims audits follow strict protocols, and one misstep can cost you significantly.

If your situation involves multiple performance categories, questions about eligibility status, or issues with third-party intermediaries, getting expert guidance can save time and money. Some practices handle straightforward TIN/NPI corrections on their own but bring in help for more complex scenarios.

Optimize your MIPS reporting and avoid common submission errors with expert tools designed to catch problems before they reach CMS.

Moving Forward

Rejections happen, but they don’t have to derail your entire MIPS performance year. The difference between a penalty and a bonus often comes down to understanding the feedback, responding within the proper timeframes, and providing complete documentation.

Focus on patient care quality while staying organized with your MIPS requirements. Document everything as you go rather than scrambling during audit season. And if something doesn’t look right in your performance feedback, don’t wait. The clock starts ticking the moment CMS releases those scores.