Confidential Feedback Reporting & Review and Corrections

Since October 2016, CMS has provided SNFs with quarterly confidential feedback reports. These reports contain information about SNFs’ performance on the readmission measure specified for the SNF VBP Program. Quarterly reports are distributed to SNFs via the Internet Quality Improvement and Evaluation System (iQIES). Quarterly reports cannot be transmitted by any means other than iQIES, as the reports contain protected health information.

When reports are disseminated to SNFs, CMS distributes email blasts through iQIES and other CMS distribution lists announcing the reports are available for download. To subscribe to CMS’s email blasts, such as the MLN Connects newsletter and the Skilled Nursing Facility - Long Term Care Open Door Forum, go to the CMS GovDelivery website.

iQIES Access

To locate quarterly reports in iQIES, please follow the instructions listed below:

1. Log into iQIES at https://iqies.cms.gov/ using a Health Care Quality Information Systems (HCQIS) Access Roles and Profile (HARP) user ID and password. 
   • If you do not have a HARP account, you may register for a HARP ID.
2. In the Reports menu, select My Reports.
3. From the My Reports page, locate the MDS 3.0 Provider Preview Reports folder. Select the MDS 3.0 Provider Preview Reports link to open the folder.
4. Here you can see the list of reports available for download. Locate the desired SNF VBP Program Quarterly Confidential Feedback Report (file name format: snfvbp_ccn_reportname.xlsx).
5. Once located, select More next to your desired SNF VBP Program Quarterly Confidential Feedback Report and the report will be downloaded through your browser. Once downloaded, open the file to view your facility’s report.

For assistance obtaining access to quarterly reports in iQIES, contact the QIES/iQIES Service Center by phone at (800) 339-9313 or by email at iqies@cms.hhs.gov.

Quarterly Confidential Feedback Reports

CMS distributes four quarterly confidential feedback reports each year: an Interim (Partial-Year) Workbook, two Full-Year Workbooks (one each for the baseline period and performance period), and a Performance Score Report.

Interim (Partial-Year) Workbook:

• Generally released in March of each year
• Contains less than a full year of data
• Contains stay-level information only
• Contains data that are not considered final

Full-Year Workbooks:

• Generally released in December (baseline period data) and June (performance period data) of each year
• Contain a full year of data
• Contain stay-level and facility-level information (i.e., SNF 30-Day All-Cause Readmission Measure [SNFRM] results)
• Contain data that are considered final

 Performance Score Report:

• Generally released in August of each year
• Contain baseline and performance period SNFRM results, performance score, SNF VBP Program rank, and incentive payment multiplier impacting the upcoming payment year

Review and Corrections

The SNF VBP Program Review and Correction (R&C) process has two phases. Correction requests are considered for up to 30 calendar days after dissemination of the applicable report.

• Phase 1: Review and submit corrections to the calculation of the readmission measure rates for the baseline and performance periods (applies to Full-Year Workbooks only) ¹
• Phase 2: Review and submit corrections to performance scores and rankings (applies to Performance Score Reports only)

SNFs must submit correction requests to the SNF VBP Program Help Desk at SNFVBP@rti.org within 30 calendar days after dissemination of the applicable report. The request must contain the SNF’s CMS Certification Number (CCN), the SNF’s name, the correction requested, and the reason for requesting the correction. If the request is related to an eligible stay, SNFs should only refer to the line number (an arbitrary unique identifier found on the ‘Eligible Stays’ tab of the quarterly confidential feedback reports) of the stay in question. Do not attach your SNF’s quarterly confidential feedback report to the request. CMS will review the requests and notify the requesting SNF of the final decision. CMS will implement any approved corrections before any affected data become publicly available.

Reports contain discharge-level data protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Any disclosure of protected health information (PHI) or personally identifiable information (PII) should only be in accordance with, and to the extent permitted by, the HIPAA Privacy and Security Rules and other applicable laws. When referring to the contents of your reports, use the line number.

The SNF VBP Program Help Desk is not secured to receive PII and PHI. The line number (an arbitrary unique identifier found on the ‘Eligible Stays’ tab of the quarterly confidential feedback reports) is a randomly assigned number and is not considered PII or PHI. 

Resources

• FY 2024 SNF VBP Program Performance Score Report User Guide (PDF) 

¹As finalized in the FY 2022 SNF PPS final rule (pages 42516-42517), beginning October 1, 2021, corrections during Phase 1 of the R&C process are limited to errors made by CMS or its contractors when calculating a SNF’s readmission measure rate. SNFs are not able to correct any of the underlying administrative claims data used to calculate a SNF’s readmission measure rate during Phase 1 of the R&C process. For corrections to the underlying administrative claims data to be reflected in the SNF VBP Program’s quarterly confidential feedback reports, the SNF must submit any claims correction requests to the Medicare Administrative Contractor (MAC) and the MAC must process the corrections before the “snapshot date.” The quarterly confidential feedback reports do not reflect any claims corrections processed after the date of the claims snapshot, which is 3 months following the last index SNF admission in the applicable baseline period or performance period. CMS cannot recalculate any results in the quarterly confidential feedback reports to reflect claims corrected after the date of the claims snapshot.