Appealing the Accreditation Award
To appeal an accreditation award or standard deficiency listed in the initial Accredited Cancer Program Performance Report, submit a cover letter with facility/network name and FIN indicating the reason for the appeal along with supporting documentation that illustrates compliance of criteria at the time of the survey Appeals will not be reviewed without appropriate supporting documentation for each standard being appealed.
All appeals should be received by the CoC within 30 DAYS of receipt of the Performance Report. Appeals are to be uploaded through the Appeals link located on the CoC Datalinks Activity Menu. Appeals are processed once a month through the Program Review Subcommittee (PRS).
The verdict of appeals will be sent by an automated e-mail notification directly to the cancer program’s contact staff (chair, liaison, administrator, and registrar) to communicate an updated Performance Report. The updated Performance Report can be accessed via the CoC Datalinks Activity Menu.
Note: Do not send in appeals and deficiency resolution documentation to the CoC at the same time as these are two different processes. Deficiency resolution documentation should not be uploaded until after the appeal response has been received by the cancer program.
2012 Commendation Standards: 2.11, 3.3, 3.7, 4.6, 5.2, 6.2, 7.2, and 8.2
2012 OAA Criteria: 2.11, 3.3, 3.7, 4.6, 5.2, 6.2, and 8.2
NOTE: 30 days after receiving your initial Performance Report, (Appeal time period), the report is final. There will be no further request for changes to Commendation standards accepted after that time period.
HIPAA and Protected Health Information
In concordance with the HIPAA guidelines, the Commission on Cancer cannot accept documentation that includes patient identifying information (protected health information [PHI]). Receipt of PHI violates the Business Associate Agreement between the American College of Surgeons and the CoC-accredited cancer program.
This applies to documentation submitted for survey, appeals, and/or deficiency resolutions. Documents that may include PHI, but are not limited to: accession lists, suspense reports, pathology reports, collected data for studies. Special care should be taken to ensure that all PHI is removed before documentation is uploaded to the SAR.
In compliance with the American College of Surgeons HIPAA Privacy and Security Policy, appropriate supervisory and managerial staff of the American College of Surgeons will be notified when documentation that includes PHI has been received. The American College of Surgeons Privacy Official will make a determination about a notification to the CoC-accredited cancer program and disposition of the documentation that includes PHI.
Programs will be required to remove or block the patient information and resubmit the documentation as soon as possible after receiving notification from the American College of Surgeons Privacy Official.
Revised February 3, 2012