Hello and thank you for your inquiry about CMS50v12 Closing the Referral Loop: Receipt of Specialist Report. The measure is designed to capture all qualifying encounters in which a referral was ordered. Notice of denial of insurance or notice of the decline from the clinician to whom the patient was referred will not count toward the communication component for closing the loop. We will explore additional denominator exclusions to reflect system reasons for not meeting the measure's communication component in a future annual update cycle.