RY2020 MassHealth Acute Hospital Pay-for-Performance Program:
Hospital Data Accuracy and Completeness Attestation Form
INSTRUCTIONS: Each Hospital must complete and submit all information provided below and sign the form. All
information must be typed in blank spaces on this PDF form.
Hospital Information
HOSPITAL NAME: INPATIENT MASSHEALTH PROVIDER ID:
STREET ADDRESS: CITY, STATE, ZIP CODE:
HOSPITAL CEO NAME PHONE
Pursuant to Section 7 of the RY2020 Executive Oce of Health and Human Services (EOHHS) Acute Hospital Request
for Application (RFA), all hospitals participating in the MassHealth Hospital Pay-for-Performance (P4P) Program must
meet data accuracy and completeness requirements on all the following information:
• Chart-abstracted measures electronic data files and online data entry of ICD population sample data submitted via
the MassQEX secure portal, and medical records submitted for data validation purposes.
• Healthcare-Associated Infection measures data reported via the CDC National Healthcare Safety Network,
• Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey data reported to CMS.
I acknowledge the above information is collected and reported in accordance with applicable requirements and reviewed
by the designated Hospital sta listed on the submitted RY2020 Hospital Quality Contact Form.
MEASURES EXMEPTION: Complete this section if the Hospital has no data for the RY2020 measurement periods
required for performance evaluation. Please enter an “X” in blank spaces to indicate the hospital has no data.
RY2020 Measurement Period
CY2019
(Q1-2019)
CY2019
(Q2-2019)
CY2019
(Q3-2019)
CY2019
(Q4-2019)
CY2017
(Q1-Q4)
CY2018
(Q1-Q4)
Perinatal Care (MAT-4, NEWB-1)
(Hospital has no Obstetric Dept.; does not deliver infants)
Central Line Assoc. Bloodstream Infection (CLABSI)
(Hospital does not meet NHSN ward locations criteria)
Catheter Assoc. Urinary Tract Infection (CAUTI)
(Hospital does not meet NHSN ward locations criteria)
Surgical Site Infections (SSI’s)
(Hospital performed a combined total of 9 or fewer colon &
abdominal hysterectomy surgeries in prior reporting year)
Patient Experience Survey data
(Hospital does not report HCAHPS data to CMS)
I certify under the pains and penalties of perjury that all information submitted is true, accurate and complete in
accordance with the applicable versions of EOHHS Technical Specifications Manuals to the best of my knowledge. I
also certify that I am the provider, in the case of a legal entity, duly authorized to act on behalf of the provider, by signing
and submitting this form on behalf of this hospital. I understand that I may be subject to civil penalties or criminal
prosecution for any falsification, omission, or concealment of any material fact contained therein.
HOSPITAL CEO SIGNATURE DATE SIGNED
MAILING INSTRUCTION: mail the complete and
signed form along with typed cover letter on hospital
stationery to the address on the right.
EOHHS MassHealth Acute Hospital P4P Program
100 Hancock Street (6
th
floor)
Quincy, MA 02171
HospDACA_2020 Form
