Value-Based Payment Modifier Reporting Form
Submit details regarding value-based payment adjustments, including provider, payment, and modifier information.
Provider or Organization Name
*
Contact Person Full Name
*
First Name
Last Name
Contact Email Address
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reporting Period (Start Date)
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reporting Period (End Date)
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Payment or Service
*
Please Select
Fee-for-Service
Bundled Payment
Capitation
Shared Savings
Performance-Based Incentive
Other
Modifier(s) Applied
*
Quality Modifier
Cost Modifier
Resource Use Modifier
Patient Experience Modifier
Efficiency Modifier
Other
Rationale for Modifier(s) Applied (Please explain the reason for applying the selected modifier(s))
*
List of Services or Claims Affected (Please specify codes, dates, or relevant details)
Upload Supporting Documentation (e.g., reports, claim summaries, justification letters)
Upload a File
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Choose a file
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Additional Comments or Notes
Signature of Reporting Individual
*
Submit Report
Submit Report
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