CMS-10210 Hospital VPB Review and Corrections Form

Hospital Value-Based Purchasing (VBP) Program

Review and Corrections Request Form

Hospitals may review and request correction of their hospitals’ performance scores on each condition, domain, and Total Performance Score (TPS). Hospitals must submit the Review and Corrections Request within 30 calendar days of the posting date of the Percentage Payment Summary Report on QualityNet (the date this report is posted is Day 1). Note: Hospitals can request an appeal only after first requesting a Review and Corrections of their performance scores. Hospitals that do not submit this formal request within 30 calendar days of Percentage Payment Summary Report posting waive eligibility to submit a CMS Hospital VBP Appeal Request for the applicable fiscal year.

Fields marked with an asterisk (*) are required.

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

*Hospital Information:

*CMS Certification Number (CCN): ____________________

*Hospital Name: ________________________________________________________________

*Hospital CEO Contact Information:

*First and Last Name:

*Email Address:

*Address (Physical street address):

*City:

*State: _____ *ZIP Code: ______________

*Telephone Number: _______________ Extension: __________

*Hospital QualityNet Security Administrator (SA) Contact Information:

*First and Last Name:

*Email Address:

*Address (Physical street address):

*City:

*State: ____ *ZIP Code: ____________

*Telephone Number: _______________ Extension: __________

*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:

P

lease 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)

Complete and submit this form via the QualityNet Secure Portal, Secure File Transfer “HVBP” group; via secure fax to 877-789-4443; or by email to [email protected].

Following receipt of the Review and Corrections Form, an email acknowledgement will be sent confirming the form has been received. Once a determination has been made, a decision of the outcome of the review will be provided.

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. Expiration Date: xx-xx-xxxx

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