CMS-10210 Hosptial Value-Based Purchasing Review and Corrections R

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: _________ * Zip Code:

* Telephone Number: _______________ ext: __________

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: _________ * Zip Code:

* Telephone Number: _______________ 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)

____________________ Provide the disputed total performance score

____________________ Provide the proposed total performance score

* 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)

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