CMS-10210 HVBP Appeal Request Form Screen Shot

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: __________

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Hospital Value-Based Purchasing Program (HVBP)
Appeal 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: _________

* 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

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Hospital Value-Based Purchasing Program (HVBP)
Appeal Request Form
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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