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: __________

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Hospital Value-Based Purchasing (VBP) Program
Review and Corrections Request Form
*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:
Please 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 (Expires xx-xx-xxxx).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 estimate(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, Maryland 21244-1850. ****CMS Disclosure**** 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 Inpatient Value, Incentives, and Quality Reporting Outreach
and Education Support Contractor at (844) 472-4477.

April 2018

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