Data Department Ticket System

Data Department Ticket System

Please complete the following Service Ticket for all EQRS assistance requests.

Network staff will follow up on all requests in the order in which they are received. Calling the Network after placing a ticket will only further delay processing times.

*Please note: This form is compliant with HIPAA and can be used to receive, maintain, or transmit PHI in accordance with their HIPAA obligations.

Please Select Your Network:*

NW 10 (IL)

NW 12 (MO, KS, IA, NE)

Please select your facility CMS Certification Number (CCN) and name from the dropdown.*

Please enter your 6-digit CCN to then select your facility. If your facility CCN is not listed, select "Not Listed" from the bottom of the drop down list. Illinois starts with 14, Iowa with 16, Kansas with 17, Missouri with 26 and Nebraska with 28.

Select

Enter Your Name*

Enter Your Email*

Select One or More Issues*

Select

Near Match Forms and Corrections to Submitted Forms

These requests can be downloaded here, filled out and then attached at the bottom of this ticket for quick and easy processing.

Near Match Potential Duplicate Form

Submitted 2728 or 2746 Form Edit Request

Need a Duplicate Patient Merge?

If, so then there is no need to complete this form. The CCSQ Help Desk can merge into a single record the same patient with multiple UPI numbers. You can create a ticket HERE or you can call them at 866-288-8912.

Indicate which record should be the primary record. Generally, if only one record has a form attached to it, that is the primary record. Otherwise, the lowest value UPI# was created first and should be the primary record.

Please List Details*

(Optional) Upload any attachments such as "Near Match" or "Forms Edit" requests.

This could be screen shots or any other document.

Drag and drop files here or

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