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: _______________
March 2017

Ext. __________
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Hospital Value-Based Purchasing (VBP) Program
Appeal Request Form
*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. 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 VBP Support
Contractor at (844) 472-4477. Expiration Date: XX-XX-XXXX

March 2017

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