CAHPS® for Physician Quality Reporting System (PQRS) Survey Discrepancy Report

Discrepancy Report Process

On occasion, a survey vendor may identify discrepancies from CAHPS for PQRS Survey protocols that require corrections to procedures and/or electronic processing to realign the activity to comply with CAHPS for PQRS Survey protocols. In its oversight role, the CAHPS for PQRS Survey project team may also identify discrepancies that require correction. 

  • Survey vendors are required to complete and submit an initial Discrepancy Report to formally notify CMS within one business day after the discrepancy has been discovered.
  • The discrepancy report notifies the CAHPS for PQRS Survey project team of the nature, timing, cause, and extent of the discrepancy, as well as the proposed correction and timeline to correct the discrepancy.
  • The survey vendor must include the Group ID number on the form.

 

Complete the Discrepancy Report in its entirety. You must submit this report online using the form provided below.

All required sections are indicated with an asterisk (*). The required information regarding the affected group practices must be provided in Section II and III in order to submit the CAHPS for PQRS Survey Discrepancy Report. If any information is unknown at time of report submission, enter “Pending” in any of the required fields in Section II and/or III. All pending information must be provided in an updated report within 7 days of submitting the Initial Discrepancy Report.

 

Discrepancy Report Form

Initial Report?

Indicate whether this report is an Initial Discrepancy Report or an Updated Discrepancy Report*

I. GENERAL INFORMATION


1. Survey Vendor Organization Information

2. Survey Vendor Contact Person

3. Date Discrepancy Was Discovered

II. *LIST ALL GROUP PRACTICE NAMES AND NUMBERS IMPACTED BY THIS DISCREPANCY REPORT

Add Another Group Practice Name/ID

Add Next Group Practice

Add Another Group Practice Name/ID

Add Next Group Practice

Add Another Group Practice Name/ID

Add Next Group Practice

Add another Group Practice Name/ID

Add Next Group Practice

Add Another Group Practice Name/ID

Add Next Group Practice

Add Another Group Practice Name/ID

Add Next Group Practice

Add Another Group Practice Name/ID

Add Next Group Practice

Add Another Group Practice Name/ID

Add Next Group Practice

Add Another Group Practice Name/ID

Add Next Group Practice

III. DISCREPANCY INFORMATION

1. * Description of discrepancy and how it was discovered 

2. *Affected timeframe for each Group Practice listed (e.g., mm/dd/yyyy - mm/dd/yyyy) 

3. * For each Group Practice listed, provide:

  1. Group Practice ID
  2. Total sampled members
  3. Number of sampled beneficiaries affected by the discrepancy

4. * Description of corrective action you've taken to address discrepancy, along with proposed timeline 

5. * Additional information not provided above which will help the CAHPS for Group Practices project team understand the discrepancy