CMS-10210 Hospital Value Based Review and Correction Request Form

Hospital Value-Based Purchasing (HVBP)
Review and Corrections Request Form
Hospitals may review and request correction of their hospital’s performance scores on each condition, domain, and
Total Performance Score (TPS). Hospitals must submit the review and correction request within 30 calendar days
of the posting date of the Value-Based Percentage Payment Summary Report on QualityNet (the date this Report
is posted to QualityNet = Day 1).
Fields marked with an asterisk (*) are required.
Note: Hospitals can only request an appeal after first requesting a review and correction of their
performance scores. Hospitals that do not submit this formal request within 30 calendar days of report
posting on My QualityNet waive eligibility to submit a CMS HVBP appeals request for the applicable fiscal
year.

Date:
* Date of Review and Corrections Request (MM/DD/YYYY): ________________________________
Hospital Contact Information:
* CMS Certification Number (CCN): ____________________
* Hospital Name:

Hospital CEO Contact Information:
* Last Name:

____________________________________________________________

* First Name:

____________________________________________________________

* E-Mail Address:

____________________________________________________________

* Address Line 1:
(Must include physical
street address)

Address Line 2:

* City:

____________________________________________________________________

* State:

_________

* Telephone Number: _______________

3/2013

* Zip Code: ____________________
ext:

__________

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Hospital Value-Based Purchasing (HVBP)
Review and Corrections Request Form

Hospital QualityNet (QNET) System Administrator (SA) Contact Information:
* Last Name: _________________________________________________________________
* First Name: _________________________________________________________________
* E-Mail Address: ______________________________________________________________
* Address Line 1:
(Must include physical
street address)

Address Line 2:

* City:

_____________________________________________________________________

* State: _________
* Telephone Number: _______________

* Zip Code: ____________________
ext:

__________

Corrections – Select all that apply (Minimum of one reason is required):
______ Condition-specific score (CSS)

____________________

Provide the disputed condition score

____________________

Provide the proposed condition score

______ Domain-specific score (DSS)

____________________
____________________

Provide the disputed domain score
Provide the proposed domain score

______ Total Performance Score (TPS)

3/2013

____________________

Provide the disputed total performance score

____________________

Provide the proposed total performance score

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Hospital Value-Based Purchasing (HVBP)
Review and Corrections Request Form
* Reasons - Please provide all evidence supporting your hospital’s claim that the CSS, DSS, and/or TPS are
incorrect. Describe the specific details for the reason of your review and request for correction of the items
selected above.

_________ *Supporting documents attached (indicate yes/no)

3/2013

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