CMS-10210 IQR Notice of Participation Form

Hospital Inpatient Quality Reporting Notice of Participation Text
Please Note: A collection tool available on the QualityNet Secure Portal allows hospitals to enter their
Notice of Participation, Contacts, and Campuses. This document is a partial representation of the text
contained in the Notice of Participation and is for reference purposes only.
Review the Notice of Participation below, choose an option, and enter your acknowledgement 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 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 procedures 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 procedures may receive a reduction in their Medicare Annual Payment Update (APU) for
the applicable fiscal year as outlined in the federal regulations. In order to avoid the reduction in their
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.
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. Please do not send
applications, claims, payments, medical records, or any documents containing sensitive information to the PRA Reports
Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved
under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have
questions or concerns regarding where to submit your documents, please contact the Hospital IQR Support Contractor
at (844) 472-4477. Expiration Date: XX-XX-XXXX

March 2017

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