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 availability to download the Percentage
Payment Summary Report on Hospital Quality Reporting (the date this report is available for
download 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 Reviews and
Corrections request within 30 calendar days of Percentage Payment Summary Report
announcement waive eligibility to later 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 Security Official Contact Information:

*First and Last Name: _________________________________________________________________
*Email Address:

____________________________________________________________

*Address (Physical street address): __________________________________________________
*City:

____________________________________________________________________

*State:

____

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*ZIP Code: ____________

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Hospital Value-Based Purchasing (VBP) Program
Review and Corrections Request Form
*Telephone Number: _______________ Extension: __________
*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 Hospital Quality Reporting Secure Portal,
Managed File Transfer to QRFormsSubmission@hsag.com; via secure fax to 877-7894443; or by email to QRFormsSubmission@hsag.com.
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 09381022 (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 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 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any

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Hospital Value-Based Purchasing (VBP) Program
Review and Corrections Request Form
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
Inpatient Value, Incentives, and Quality Reporting Outreach and Education Support Contractor at (844) 472-4477.

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