CMS-10210 HVBP Appeal Request Form

Hospital Value-Based Purchasing Program (HVBP)

Appeal Request Form

Hospitals may appeal the calculation of their performance assessment with respect to the performance standards, as well as their Total Performance Score (TPS). Hospitals may submit an appeal within 30 calendar days of the date of the CMS review and corrections decision letter.

Fields marked with an asterisk (*) are required.

Note: Hospitals must receive an adverse determination from CMS of their review and corrections request prior to requesting an appeal for the applicable fiscal year.

Dates:

*Date of Appeal Request (MM/DD/YYYY): ________________________

*Date of Review and Corrections Request (MM/DD/YYYY): ________________________

*Date of Review and Corrections Decision from CMS (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: __________

Basis for Requesting Appeal - Select all that apply (Minimum of one reason is required):

Denial of hospital’s correction request submitted under the review and corrections process

Calculation of Achievement/Improvement points

Calculation of Measure/Dimension score - the higher of the achievement/improvement points was not used in the calculation

Calculation of Domain scores, including normalization calculation

Calculation of HCAHPS Consistency Points – the lowest dimension score was not used in the calculation

Calculation of HCAHPS Consistency Points

Incorrect domain scores used in TPS calculation

Incorrect weight applied to the domain

Incorrect weighted domain scores summed to calculate TPS

Hospital’s open/closed status, including mergers and acquisitions, not correctly specified in CMS systems

Describe the specific reason for each of the appeal items selected above for the hospital’s request to appeal.

_______ *Supporting documents attached (indicate yes/no)

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