EQRS Service Desk Ticket

EQRS Service Desk Ticket

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.

Date of Request*

Please Select Your Network:*

Select Network 8 - For states Alabama, Mississippi, or Tennessee Select Network 14 - For states Texas

Network 8

Network 14

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 dropdown. Alabama will begin with 01 Mississippi will begin with 25 Tennessee will begin with 44 Texas will begin with 45, 67 or 74

Select or enter value

CCN not listed in Dropdown*

If your CCN and Facility Name are not listed please enter the name of your facility.

Assistance requested*

If you are having difficulties admitting a patient please select Cannot Admit Due to Possible Duplicate/ Near Match

Select

Has the 2728 already been submitted?*

YES

When was the 2728 Submitted?*

What modifications need to be made on the 2728?*

Please Format your response like so:

Field Number - New Value - Reason for Change

Is 2746 Submitted*

YES

2746 Date of Death*

2746 Cause of Death*

Select

Enter Patient EQRS ID (CROWNWEB UPI)

If available please provide the patients EQRS ID Number also know as CROWNWeb UPI .

What modifications need to be made on the 2746?*

Please Format your response like so:

Field Number - New Value - Reason for Change

For submitted 2728 & 2746 Modification Request:

Networks are limited to what we can change. We are unable to delete submitted forms and unable to make changes to physician names or signature dates. These requests must be made to the Quality Net Helpdesk at 866-288-8912 or by email at qnetsupport-esrd@cms.hhs.gov

Edit requests must be made within 2 months from the date the form was submitted in EQRS. For forms with a submission dater older than 2 months contact the Quality Net Helpdesk.
Only the facility that originally submitted the form may request a change to that submitted form.
Any changes made to already submitted forms will change the submission date in EQRS which may negatively impact your forms compliance.

Never email PHI/PII (patient names, birthdates, etc.) to the Network. All violations will be reported to CMS!!

I have read and acknowledge the above statement*

Details for requests:*

Please provide additional details for the issue(s) you need assistance with.

Name of person completing the request*

Please provide the name of the person completing this request for assistance. This will be the person that the Network will contact.

Email Address*

Please provide the email address where you can be contacted.

Be sure to press ENTER after typing in your email address.

Select or enter value

Telephone Number*

Please provide the telephone number where you can be reached.

Phone

Possible Duplicate/Near Match Form

To assist with admitting the patient into EQRS, please fill out the form below.

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

Patient First Name*

Please enter the patient's first name

Patient Last Name*

Please enter the patient's last name

Social Security Number

Please enter just the number no dash marks (-)

Medicare Beneficiary Identifier

This is the patient's Medicare Number

Date of Birth*

Required for EQRS admission

Sex:*

Required for EQRS admission

Male

Female

Admit Date*

Required for EQRS admission

Admit Reason*

Required for EQRS admission

Select

Primary Dialysis Setting*

Required for EQRS admission

Select

Primary Treatment*

Required for EQRS admission

Select

If Hemo Session per week

If Hemo Time per session

Attending Physician

2744 Assistance

For 2744 assistance, please schedule an appointment here: APPOINTMENT

Merge Record Assistance:

Duplicate UPIs for the same patient are resolved through creating a ticket for the QualityNet Help Desk. 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.

Send me a copy of my responses

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