CMS-10431 Data Accuracy and Completeness Form

Changes for FY 2025 DACA

Please Note: A data collection tool available within the Hospital Quality Reporting system via the Hospital Quality Reporting Secure Portal allows hospitals to complete and submit their DACA. This document is a representation of the text contained in the DACA and is for reference purposes only.

Data Accuracy and Completeness Acknowledgement (DACA)

FY Drop down selection: 2025

The DACA is an annual requirement for providers participating in the Hospital IQR, IPFQR, and PCHQR Programs to electronically acknowledge that the data submitted to these programs by or on behalf of the providers are accurate and complete to the best of their knowledge.

Fiscal Year

PCHQR

Data Accuracy and Completeness Acknowledgement (DACA)

To the best of my knowledge, at the time of submission of this form, all of the information reported for this hospital for participation in the PCHQR Program is accurate and complete. This acknowledgement is for information submitted since the completion of the Fiscal Year (FY) 2024 DACA signed in Calendar Year 2023. This information includes the following:

• Measure data, as defined for the PCHQR Program

• All Program requirements, as defined for the PCHQR Program (e.g., where applicable, chart abstraction and/or sampling)

• Current Notice of Participation

I understand this acknowledgement covers all PCHQR information reported by this hospital (and any data or survey information reported by vendor(s) acting as agents on behalf of this hospital) to the Centers for Medicare & Medicaid Services (CMS) and its contractors. The data submitted in the time frame covered by this DACA are required for purposes of meeting the requirements for FYs 2024, 2025, and 2026 as specified in the Final Rules governing the PCHQR Program.

To the best of my knowledge, at the time of submission, this information was collected in accordance with all applicable requirements. I understand that this information is used as the basis for reporting quality of care and patient assessment of care to the public.

Submission Period:

07/01/2024 - 08/31/2024

With Respect to Reporting Period:

09/01/2023 - 08/31/2024

Paperwork Reduction Act (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 0938-1175. The expiration date is 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 21244-1650.