Last updated: November 2026
A hospital quality reporting program build is the written set of owners, backups, calendar and procedures that gets a hospital's data to CMS for the Hospital Inpatient Quality Reporting (IQR) Program and the Hospital Outpatient Quality Reporting (OQR) Program, and carries it through validation, exceptions and any reconsideration. Integral Healthcare Solutions (IHS) has three practice lines (Accreditation Consulting, Compliance Services and Program Development), and this build sits in Program Development. IHS drafts the program for your leaders to adopt; your clinicians approve the clinical abstraction rules, and the hospital submits to CMS.
What do the IQR and OQR regulations require?
The IQR Program is governed by 42 CFR 412.140 and the OQR Program by 42 CFR 419.46. IHS read the current eCFR text of both through the GPO bulk data (built November 4, 2026).
IQR, 42 CFR 412.140
- Joining (section 412.140(a)): register on QualityNet before reporting, register a security official, and file a Notice of Participation Form if the hospital is new, is returning after a withdrawal, or has a new CMS Certification Number.
- Withdrawal (section 412.140(b)(2)): CMS accepts forms on or before May 15 of the fiscal year before the payment determination year, beginning with the FY 2016 payment determination.
- Validation (section 412.140(d)): charts go to CMS within 30 days of the date on a written request; the chart-abstracted requirement is a 75-percent score.
- Reconsideration (section 412.140(e)): the request must contain items including the CCN, contacts for the chief executive officer and security official, an explanation of why the hospital believes it complied, and supporting evidence such as patient charts and e-mails.
OQR, 42 CFR 419.46
- Payment consequence (section 419.46(a)): the regulation states that the statute authorizes a 2.0 percentage point reduction in the OPD fee schedule increase factor for a subsection (d) hospital that does not submit the data required on measures in accordance with the Secretary's requirements.
- Withdrawal (section 419.46(c)): up to and including August 31 of the year before the affected updates. A withdrawn hospital cannot sign up for that update later and is subject to a reduced annual payment update.
- Submission (section 419.46(d)): deadlines by measure and data type are on the CMS website; a deadline on a weekend, legal holiday or federal non-work day moves to the next day that is not one. Hospitals sharing a CCN combine data collection and submission across campuses for all clinical measures for public reporting. Data can be corrected during the review and corrections period, and not after the submission deadline.
- Validation (section 419.46(f)): a hospital that is selected and receives a score for validation of chart-abstracted measures may request an educational review within 30 calendar days from the date the validation results are made available.
The two programs run on different clocks: IQR by fiscal year with December 31 and May 15 dates, OQR by calendar year with August 31 and March 17 dates. That comparison is IHS's reading of the two texts. One owner map and one calendar can cover both, which is the build IHS drafts.
Who needs this build and what triggers it
Any hospital reporting under IQR or OQR needs a named owner for each dated step. Five situations usually start the work:
- A hospital is new to a program or has a new CCN.
- A hospital is selected for validation and has 30 days to send charts or records.
- Staff turnover leaves no named owner for a dated step.
- A notification letter arrives and a 30-day reconsideration clock starts.
- An outage or disaster raises an extraordinary circumstance request.
How IHS helps
IHS starts with a gap review of your reporting practice against the two sections, maps each duty to an owner and a piece of evidence, drafts the program documents, and tests them with a tabletop run before a real validation request arrives.
What IHS drafts
- A program charter for IQR and OQR reporting.
- An owner-and-backup matrix for registration, submission, review and correction, validation, reconsideration and exceptions.
- One combined IQR and OQR submission and review-and-correct calendar.
- A validation-response procedure with a chart-pull log, so a 30-day request is tracked from the day it arrives.
- A reconsideration and extraordinary circumstance decision checklist, and an evidence file for leadership review.
What you supply
You supply your CMS Certification Numbers, system roles and security-official designations, your current CMS measure list, abstraction vendor contracts, prior validation results and the people who will own each task.
The real limit
IHS does not abstract charts, submit data, register users or contact CMS or its contractors. The hospital submits. The measure list, specifications and current-year deadlines come from the CMS materials in force when the calendar is built; section 419.46(d)(2) itself points to the CMS website for deadlines.
What to have ready
Gather these before the first working session. Each ties to the section named.
- Proof of QualityNet and OQR system registration, with the users and security officials (sections 412.140(a), 419.46(b)).
- The Notice of Participation and its filing date, or the new-CCN open date (section 412.140(a)(3)).
- Any past extraordinary circumstance request, with event and request dates (sections 412.140(c)(2), 419.46(e)).
- The last written chart or record request and the date the submission went back (sections 412.140(d)(1), 419.46(f)(1)).
- Your last IQR validation score and OQR reliability score (sections 412.140(d)(2), 419.46(f)(2)).
- The last Annual Payment Update Notification Letter and any reconsideration request (sections 412.140(e), 419.46(g)).
- The current CMS OQR deadline list (section 419.46(d)(2)).
- Abstraction vendor contracts and the list of who owns each reporting task.
A free introductory call is the place to walk through this list and agree what IHS drafts first.
How do IQR and OQR compare?
This table states what each section says, as read on November 5, 2026, without telling you which applies to your hospital.
| Item | IQR, 42 CFR 412.140 | OQR, 42 CFR 419.46 |
|---|---|---|
| Joining | Notice of Participation by December 31 before the first data quarter (first-time or returning); 180 days from the open date (new CCN) | Register before reporting; submit at least one data element |
| Withdrawal | On or before May 15 of the fiscal year before the payment determination | Up to and including August 31 of the year before the affected updates |
| Chart or record request | 30 days from the date identified on the written request | 30 days from the date identified on the written request |
| Validation score | 75-percent score (chart-abstracted); eCQM rule changes at FY 2028 | At least a 75-percent reliability score |
| Exception request | 60 calendar days from the event | 60 calendar days from the event |
| Reconsideration | 30 days from the date on the notification letter | March 17 of the affected payment year, or the next work day |
| Further appeal | Provider Reimbursement Review Board | Provider Reimbursement Review Board |
The programs share a 75-percent threshold, a 30-day request window, a 60-day exception window and an appeal body, so one validation procedure can serve both; the calendar lists the differing dates separately. A general quality improvement program, such as our quality improvement program build, covers internal quality work; this page covers the CMS reporting duties only.
What does it cost?
CMS charges no fee for these programs in the sections reviewed, so the costs are consulting and your own staff time.
- Authority fees: none. Sections 412.140 and 419.46 set no fee for participating or reporting.
- Consulting fees: IHS scopes each engagement after a free introductory call. Scope depends on the number of hospitals and CCNs, IQR, OQR or both, and the gaps the first review finds.
- Your internal time: your quality lead, the people who register and submit, and the abstractors build the owner list and run the procedures. IHS publishes no staff-hour estimate.
What this is not
- It is not legal advice. IHS is a consulting firm, not a law firm. Counsel reads the statute and annual rules on payment consequences.
- It is not a guarantee of a validation score or CMS payment decision.
- It is not a reporting service. IHS does not abstract charts, submit data, register users or contact CMS or its contractors.
Frequently asked questions
What are the Hospital IQR and OQR program requirements in the CFR?
The Hospital Inpatient Quality Reporting (IQR) Program is set out in 42 CFR 412.140 and the Hospital Outpatient Quality Reporting (OQR) Program in 42 CFR 419.46. Both cover registration with a security official, data submission in the form, manner and time CMS specifies, extraordinary circumstance exceptions, validation and reconsideration.
Who needs to be registered in QualityNet, and who is the security official?
An IQR hospital must register on the QualityNet website before it begins to report data and must identify and register a QualityNet security official (section 412.140(a)(1) and (2)). An OQR hospital must register on the CMS-designated information system and register a security official there (section 419.46(b)(1) and (2)).
What happens if we miss data submission?
For OQR, section 419.46(a) says the statute authorizes a 2.0 percentage point reduction in the OPD fee schedule increase factor for a subsection (d) hospital that does not submit data required to be submitted on measures in accordance with the Secretary's requirements. IHS states no IQR payment amount; the text opened has none. A hospital that disagrees with a CMS finding may seek reconsideration, within 30 days of the notification letter for IQR and by March 17 of the payment year for OQR. Counsel reads the statute for the payment effect.
How does validation work and how fast must we send charts?
On written request from CMS or its contractor, an IQR hospital must submit the requested sample of patient charts within 30 days of the date identified on the request (section 412.140(d)(1)), and an OQR hospital must submit the supporting medical record documentation within 30 days of the date identified on the request (section 419.46(f)(1)). Log the request date the day it arrives.
What score do we need to pass validation?
IQR chart-abstracted validation requires a 75-percent score, as determined by CMS (section 412.140(d)(2)(i)). OQR requires at least a 75-percent reliability score, as determined by CMS (section 419.46(f)(2)). IQR eCQM validation changes with the payment year: 100 percent of sampled records, timely and complete, before the FY 2028 payment determination, and a 75-percent score from FY 2028 on (section 412.140(d)(2)(ii)).
Can we ask for an extraordinary circumstance exception, and by when?
Yes, under both programs, within 60 calendar days of the date the extraordinary circumstance occurred, using the information CMS specifies at QualityNet or a successor website (sections 412.140(c)(2)(ii)(A) and 419.46(e)(2)(i)). CMS decides in writing by email, and may grant one on its own for a systemic CMS data problem or a regional event.
How do we appeal a CMS decision on our reporting?
Ask CMS for reconsideration first. For IQR, file no later than 30 days from the date identified on the Annual Payment Update Notification Letter, except as provided for extraordinary circumstances (section 412.140(e)(1)). For OQR, file through the CMS-designated information system by March 17 of the affected payment year, or the first work day after it, with the same exception (section 419.46(g)(1)). A hospital dissatisfied with the result may appeal to the Provider Reimbursement Review Board.
When must a new hospital file its Notice of Participation?
A first-time or returning IQR hospital, other than one covered by the new-CCN rule below, files by December 31 of the calendar year before the first quarter of the calendar year in which data submission is required for the fiscal year (section 412.140(a)(3)(i)). A hospital with a new CMS Certification Number files no later than 180 days from the open date on the approved CMS Quality Improvement Evaluation System (section 412.140(a)(3)(ii)).
What belongs in an annual quality reporting calendar?
The dates in the two sections, the CMS-posted OQR deadlines (section 419.46(d)(2)), both withdrawal dates, the OQR corrections period, and the 30-day and 60-day windows. IHS builds one combined IQR and OQR calendar and marks each date with its source section or CMS page.