Revision History


If a unit does not pass accreditation, the facility has the opportunity to submit an option form to proceed with accreditation through an appeal or repeat, to withdraw the module or patient type in question, or to withdraw from the accreditation process entirely. These options are described in detail below.


To access your option form, go to “My Final Reports” and click “Select Option” under the option status column.



For CD or film submissions, the option form is available 48 hours after images are returned to your facility. For uploaded submissions, the option form is available 48 hours after the final report is issued.


Option forms are due 15 days after the date they are sent. Please review your final report and options with your supervising physician before completing your option form. Your final report must be viewed before the option form is available.


Mammography and Radiation Oncology: The available options after accreditation failures and deficiencies, as well as the appeal and repeat procedures for mammography and radiation oncology differ from those for other modalities. Information and instructions for mammography and radiation oncology are provided separately.



Appeals

Appeals are typically made due to disagreement with the assessment of image quality and/or missing images or incorrect data forms.

Facilities that disagree with a deficiency or failure may appeal the determination within 15 days of the final report. Only those images reviewed for the original determination will be considered during the appeal evaluation.


If you did not pass accreditation because your technologists selected and submitted the wrong images, omitted required images, and/or provided insufficient information with the images submitted, you may appeal the decision; however, you may not submit new cases. During accreditation review, the ACR reviewers assume that the submitted cases were reviewed by the modality’s supervising physician (as specified in the Testing Instructions) and are examples of your best work. Consequently, during an appeal, only the original exam will be reviewed. If some sequences from the original exam were not included, you may be able to submit those sequences.


To appeal, complete the option form in the online accreditation system:

  1. Go to “My Final Reports”

  2. Click “Select Option”

  3. Select “other options”

  4. Select “appeal”

  5. Check the attestation box at the bottom of the screen. Do NOT check any modules or patient types on this screen unless you wish to withdraw them from the accreditation process.

  6. Click “Submit”


Appeal submissions must be completed the same way as the original submission. If you submitted on CD, you must appeal on CD; if you submitted electronically, you must appeal electronically.


Appeals on film or CD Submissions: Once you submit your option form stating your intent to appeal, your appeal items must be returned to ACR within 10 days. You only need to submit failed items for appeal. Passing exams should not be resubmitted. You must submit the exams and paperwork previously scored with your appeal submission. Appeal submission materials include:

  • Letter stating the reason for appeal: If clinical, the letter must be signed by the supervising physician. If both clinical and phantom images are being appealed, please send two letters: one letter addressing the clinical appeal and one letter addressing the phantom appeal. 

  • CD: If appealing for disagreement on image quality assessment, submit one original CD that was submitted to the ACR. If appealing due to missing images acquired on the same date of service as images originally submitted, you may burn an appeal CD to submit along with the original CD. The appeal CD must contain all required series, not just the images missing from the original submission. Write “Appeal” with a permanent marker on the appeal CD.

  • Data form for exam(s) being appealed (if applicable): If appealing for disagreement on image quality assessment, submit one original data form. If appealing due to incorrect data form, submit one original data form and a corrected copy labeled “Appeal.”


Mail your appeal materials to:

The American College of Radiology

ATTN: Diagnostic Modality Accreditation Program

1891 Preston White Drive

Reston, VA 20191


Please note that your accreditation submission contains HIPAA data, so we strongly recommend that you send your submission via a traceable method with a signature required for delivery.


Appeals on Electronic Submissions: When completing the option form as outlined above, please have all materials outlined below available, and proceed as follows:

  • Upload appeal letter signed by supervising physician (if clinical) or medical physicist (if phantom)

  • Upload any supporting documentation such as corrected phantom data forms

  • If additional images are required, select “yes” for submission of additional images; select “no” if no additional images need to be uploaded

  • Submit the options form online

  • Upload the missing images in the testing package; Do NOT re-upload the entire exam

  • Submit the online testing package in the accreditation system


Your images will be forwarded to an arbitrator (a reviewer who did not participate in the initial review) with a copy of the previous reviews and the appeal letter written by the facility. The arbitrator's determination will be final.


You should receive the appeal results within 30 to 45 days of the date all required appeal materials were received by the ACR.


If the appeal outcome following the first deficiency is a fail, you may choose to repeat, withdraw the module/patient type, or withdraw from accreditation. 

 

Repeats

If your facility does not pass accreditation on the first attempt, you will not have to redo the entire process; you only have to undergo the process again in those exams or categories found to be deficient. For example, a Breast Ultrasound facility that received a deficiency in the Core Needle Biopsy category would need to take corrective action and submit a new Core Needle Biopsy case; a Breast Ultrasound facility that received a deficiency in the Breast Ultrasound category would need to take corrective action and submit both a new simple cyst case and a solid mass case.


Choose this option if your facility wishes to submit a new exam of the same type in the category that did not pass. Exam changes are not permitted in a repeat cycle. You may submit a clinical or phantom image collected after the date on the deficiency report and not previously submitted for ACR review. For clinical examinations, repeat those examinations on a different patient. For phantom images, repeat the phantom scans, ideally with the assistance and supervision of a qualified medical physicist or MR scientist, as applicable.


If you failed accreditation due to incomplete labeling of images, you may not simply resubmit the same case for repeat, adding the information that was missing. Once a case has been submitted for accreditation and deemed unacceptable, that same case cannot be resubmitted for accreditation for any reason.


You do not need to resubmit passing exams in a repeat cycle.


Requests for repeat should be submitted within 15 days of receiving the report. To choose this option:

  • Complete the option form in the online accreditation system

    • Go to 'My Final Reports", click "Select Option"

    • Go to "My Final Reports" and click "Select Option"

    • Select "other options"

    • Select “repeat”

    • Check the attestation box at the bottom of the screen. Do NOT check any modules or patient types on this screen unless you wish to withdraw them from the accreditation process.

    • Click “Submit”

  • Submit the repeat application and payment

  • You will receive your testing package and due date after the repeat application is accepted

 

If the repeat does not pass, you may choose to appeal the repeat images only, reinstate with corrective action, withdraw the module/patient type, or withdraw from accreditation.

 

Withdraw Module/Patient Type

If your facility does not perform the recommended minimum number of exams within a failed module, you may be able to drop the module. Please refer to the Emergency Use Clause in your modality’s program requirements for more information. Some modalities require all patient types to be accredited and may not have an emergency use clause. Although accreditation is voluntary, all ACR accredited sites must comply with ACR program requirements.


Please note that some third-party payers may have stricter minimum requirements for reimbursements. The ACR does not maintain a list of these payers and their requirements; you may want to check with the payer before dropping a module.


To choose this option:

  • Complete the option form in the online accreditation system

    • Go to “My Final Reports”, click “Select Option”

    • Select “other options”

    • Check all modules or patient types you wish to withdraw from the accreditation process

    • Check the attestation box at the bottom of the screen.

    • Click “Submit”

  • Submit the Withdraw Module/Patient Type Form signed by the listed supervising physician. Forms may be faxed to 703-295-6776. 

 

Withdraw

Choose this option if you wish to withdraw from the accreditation process entirely. Should you withdraw, you must remove any ACR accreditation signage on display.  


A Note Regarding Equipment Performance/Protocol Problems: If you did not pass accreditation on your first attempt, and ACR reviewers noted potential performance problems associated with your equipment or your choice of protocol, you should contact your medical physicist/MR scientist for assistance. When ACR reviewers report image quality problems on cases submitted for accreditation, it is not always possible to exactly identify the cause of the deficiencies. Reviewers will provide “possible” causes to help direct the facility in correcting the problem. Your medical physicist/MR scientist can be invaluable in helping you identify and eliminate problems that are technical in nature by reviewing your protocols and/or conducting focused tests on the equipment.





Revision History for this Article

Date

Section

Description of Revision(s)

12-12-19

All

Article created; FAQs incorporated; No criteria changes



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