Payment

Scoring Calculations Review and Correction Process

The Centers for Medicare & Medicaid Services (CMS) provides hospitals with detailed Hospital-Acquired Condition (HAC) Reduction Program data and results in confidential Hospital-Specific Reports (HSRs). CMS gives hospitals 30 days to review their HAC Reduction Program data, submit questions about the calculation of their results, and request corrections to the following information:

• Measure result for the CMS Patient Safety and Adverse Events Composite (CMS PSI 90) measure
• Measure scores for each of the measures:
• CMS PSI 90
• Central Line-Associated Bloodstream Infection (CLABSI)
• Catheter-Associated Urinary Tract Infection (CAUTI)
• Colon and Abdominal Hysterectomy Surgical Site Infection (SSI)
• Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia
• Clostridium difficile Infection (CDI)
• Total HAC Score
• Payment reduction status

The Scoring Calculations Review and Correction period begins when CMS makes HSRs available via the Hospital Quality Reporting (HQR) system. For fiscal year (FY) 2027, the 30-day Scoring Calculations Review and Correction period extends from September 10, 2026 to October 9, 2026.

If hospitals identify potential discrepancies in the calculation of their CMS PSI 90 measure result, CMS PSI 90 measure score, healthcare-associated infection (HAI) measure scores, Total HAC Score, or payment reduction status, they can request a review of the calculations by using the QualityNet Question and Answer Tool no later than 11:59 p.m. PT on the final day of the Scoring Calculations Review and Correction period. During the Scoring Calculations Review and Correction period, hospitals cannot request corrections to the Centers for Disease Control and Prevention's (CDC’s) National Healthcare Safety Network (NHSN) HAI data but may ask clarifying questions about standardized infection ratio (that is, the measure result for the CDC’s NHSN HAI measures) calculations. 

To submit a correction request, users should select “HACRP” from the program list and “HACRP Review & Correction Requests” as the topic. Users should describe the reason for requesting a review and include the following information in the email:

• CMS Certification Number
• Hospital name
• Hospital address
• Contact person's name, phone number, and email address
• Score(s) to be reviewed (include all that apply)

Hospitals should NOT include personally identifiable information (PII) and protected health information (PHI) in their request. Emailing PII and PHI is a security violation.

Replication of HAC Reduction Program Results

The HAC Reduction Program HSRs and HSR user guide contain the data necessary to replicate HAC Reduction Program calculations.

The HSRs include patient-level data to replicate a hospital’s CMS PSI 90 composite value and hospital-level data to replicate the measure scores for the six measures included in the program. 

The HSR user guide contains national results and composite weights needed to replicate the measures scores. The HSR user guide also details how to replicate these elements and your hospital's Total HAC Score. 

Note: The Scoring Calculations Review and Correction period does not allow hospitals to request corrections to the following:

1. The underlying claims data for the CMS PSI 90 (this includes adding new claims to the data extract CMS used to calculate the results).
2. Reported number of HAIs, standardized infection ratios, and reported central-line days, urinary catheter days, surgical procedures performed, or patient days for the CDC's NHSN HAI measures.
   

Each year, CMS takes an annual snapshot of the claims data used to perform measure calculations for the CMS PSI 90 measure. The snapshot for the FY 2027 HAC Reduction Program occurred on October 31, 2025. The HAC Reduction Program HSR will not reflect revisions to claims processed after the snapshot. The next snapshot for the claims-based measures will be after the last business day of September to calculate results for FY 2028.

Hospitals can submit, review, and correct the chart-abstracted and hospital-level information used to calculate measure results for the CDC's NHSN HAI measures within the NHSN system during the approximately four and a half months following the end of the reporting quarter up until the applicable CMS submission deadline noted in the HAC Reduction Program Key Dates document.

Validation Reconsideration

As assuring data accuracy is vital to public reporting and payment purposes, the Centers for Medicare & Medicaid Services (CMS) assesses the accuracy of healthcare-associated infections (HAI) data in the Hospital-Acquired Condition (HAC) Reduction Program through the validation process. CMS verifies on a quarterly basis that data submitted to the Centers for Disease Control and Prevention’s National Healthcare Safety Network can be reproduced by a trained abstractor using a standardized protocol.

For the HAC Reduction Program, after the validation of all applicable validation quarters of the program year have been completed, CMS calculates a total score reflecting the accuracy of the reported HAI measures data. After the educational review results are considered, CMS computes a confidence interval around the score. If the upper bound of this confidence interval is 75 percent or higher, the hospital will be in compliance with the HAC Reduction Program validation requirement; if the upper bound is below 75 percent, the hospital will not be in compliance with the HAC Reduction Program validation requirement and will be assigned the maximum Winsorized z-score (worst) score for the measures validated. Hospitals that do not meet the validation requirement will also automatically be selected for inpatient validation in the next year. For more information on the validation process, refer to the QualityNet Inpatient Data Validation Resources page.

CMS provides hospitals that do not meet the validation requirement with the opportunity to request a reconsideration of this validation decision. Hospitals that would like to request a reconsideration must submit a completed “Validation Review for Reconsideration Request” form. Hospitals should not resubmit a copy of a medical record that was previously sent to the Clinical Data Abstraction Center Contractor. The “Validation Review for Reconsideration Request” form must be received for review by the Validation Support Contractor via the Hospital Quality Reporting Secure Portal, Unified File Management (UFM)/Managed File Transfer (MFT) “Validation Support Contractor” group by the deadline identified on the HAC Reduction Program Data Validation Notification Letter. If unable to submit via UFM/MFT, you may mail to:

Telligen
Attn: Validation Support Contractor
1776 West Lakes Parkway
West Des Moines, IA 50266