CMS-10210 HIQR Notice of Participation Form

Hospital Inpatient Quality Reporting (IQR) Program Notice of Participation Text

Review the Notice of Participation below, choose an option and enter your Password to confirm.

Hospital Inpatient Quality Reporting Program Notice of Participation (Pledge Form) - Agreement

The hospital agrees to follow procedures for participating in the Hospital Inpatient Quality Reporting (IQR) Program as outlined in the federal regulations found in the Federal Register, or is indicating its decision to decline participation.

Each hospital must complete this "Hospital IQR Notice of Participation" as outlined in the Hospital IQR Reference Checklist on QualityNet and in the federal regulations found in the Federal Register. In an effort to alleviate the burden associated with submitting this form annually, effective with the Hospital IQR Notice submitted for participation in FY 2008 or later, a hospital that indicated its intent to participate will be considered an active Hospital IQR participant until CMS determines a need to pledge again, or the hospital submits a withdrawal to CMS.

This information is in compliance with the CMS guidelines for hospitals submitting their quality performance data in accordance with Section 5001(b) of the Deficit Reduction Act of 2005. Hospitals that do not follow the guidelines as outlined in the federal regulations may receive a reduction in their Medicare Annual Payment Update (APU) for the applicable fiscal year. In order to avoid the reduction in their Annual Payment Update, hospitals must also continue to display quality information for public viewing as required by section 1886(b)(3)(B)(viii)(VII) of the Social Security Act. Before this information is displayed, hospitals will be permitted to review their information as it is recorded. Based on section 1886(b)(3)(B)(viii)(V) of the Social Security Act, for payments beginning with FY 2008, CMS is required to add other measures that reflect consensus among affected parties. Eligible hospitals must follow the regulations as outlined in the federal regulations and as summarized in the Hospital IQR Reference Checklist on QualityNet.

In order to receive the full market basket update, CMS must publish on Hospital Compare the hospital's submitted data for the required measures. Data aggregated at the hospital level will be provided to the Secretary.

A hospital’s choice of participating in the Hospital IQR Program for APU may affect eligibility for the Hospital Inpatient Value Based Purchasing program. Agreeing to participate in the Hospital IQR Program is one of the requirements to be eligible for the Hospital Inpatient Value Based Purchasing program. It is important to note that non-participation in or withdrawal from the Hospital IQR Program, may exclude a hospital from eligibility for the Hospital Inpatient Value Based Purchasing program. This is pursuant to Section 1886(o)(1)(C)(ii)(I) of the Social Security Act, a hospital “that is subject to the payment reduction under subsection (b)(3)(B)(viii)(I) for such fiscal year” is excluded from the Hospital VBP Program.

We entities operating under the submitted Provider ID...

Agree to participate. ______

Do not agree to participate. ______

Request to be withdrawn from participation. ______

This acknowledgement (to participate or not to participate or to withdraw) remains in effect until an electronically signed acknowledgement applying changes has been entered.

By entering my password, I hereby issue this Hospital IQR Notice of Participation with the specified direction contained within:

Please Note: A collection tool available on My QualityNet allows hospitals to enter their Notice of Participation, Contact, Campus information and National Provider Identifiers (NPI). To access the collection tool, on the My Task screen in the Manage Pledges section, select the “View/Edit Notices of Participation, Contacts, Campuses, NPIs link”.

This material was prepared by Telligen, Hospital Inpatient Quality Reporting Program Support Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. 10SoW-IA-HIQRP-10/12-248 10/2012

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