CMS-10210 VBP Appeal Request Form

Hospital Value-Based Purchasing (VBP) Program

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 must submit an Appeal Request within 30 calendar days from the date the Centers for Medicare & Medicaid Services (CMS) informed the hospital through QualityNet of its decision on the Review and Corrections Request. 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.

Fields marked with an asterisk (*) are required.

*Review and Corrections and Appeal Information:

*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 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: _________________ Ext. __________

*Hospital QualityNet Security Administrator (SA) Contact Information:

*First and Last Name:

*Email Address:

*Address (Physical street address): ___________________________________________________

*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

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

*Reason:

*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)

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 Appeal Request Form, an email acknowledgement will be sent confirming the form has been received. Once a determination has been made, CMS will provide a decision of the outcome of the appeal.

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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