CMS-10210 IQR 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 IQR Program Notice of Participation (Pledge Form) – Agreement
The hospital agrees to follow procedures for participating in the Hospital 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 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 the Centers for Medicare & Medicaid Services (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 of one-fourth of
the applicable percentage increase of the market basket update for the applicable fiscal year. In order to
avoid the reduction in their Annual Payment Update (APU), 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 (VBP) Program. Agreeing to participate in the Hospital IQR
Program is one of the requirements to be eligible for the Hospital Inpatient VBP 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 VBP 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 the QualityNet Secure Portal allows hospitals to enter their
Notice of Participation, Contacts, and Campuses. To access the collection tool, in the Manage Notice of
Participation section on the My Tasks screen, select the “View/Edit Notice of Participation, Contacts,
Campuses” link.
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1022.The time required
to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions,
search existing data resources, gather the data needed, and complete and review the information collection. If you have comments
concerning the accuracy of the time estimates(s) or suggestions for improving this form, please write to CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, MD 21244-1650.

Updated February 2015

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