Form CMS-10392 Qualified Entity Application

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

DRAFT QUALIFIED ENTITY
APPLICATION

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write to: CMS, Attn: Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

QUALIFIED ENTITY APPLICANT DATA SHEET
Qualified Entity Information
Applicant Legal Name

Date Submitted

Trade Name/DBA

Date Received by CMS

Address

ZIP Code

City, State
Type of Applicant
For Profit Organization

Not for Profit Organization

Other __________________________

Applicant’s Employer Identification Number

Application Contact Person Information
Last Name, First Name, Salutation

Title

Phone Number

Fax Number

Address

City, State

ZIP Code

Signature
To the best of my knowledge and belief, all data in this application are true and correct, the document has been duly authorized by
the governing body of the applicant and the applicant will comply with the terms and conditions of the award and applicable
Federal requirements if awarded.
Type Name and Title of Authorized Representative
Telephone Number (include area code)
Signature of Authorized Representative

Date Signed (mm/dd/yyyy)

DRAFT QUAIFIED ENTITY APPLICATION
This application provides an opportunity for eligible organizations to apply to serve as a qualified
entity.
Due Date

Application Submission
Application Content
Each of the following elements must be explained and described using plain language. Applicants are
encouraged to submit supporting documentation, where appropriate.
Qualified entity organizational and governance capabilities
Describe past experiences or future plans for accurately calculating quality, efficiency, effectiveness, and
resource use measures from claims data, including:
(A)
(B)
(C)
(D)
(E)
(F)

Indentifying an appropriate method to attribute a particular patient’s services to specific
providers of services and suppliers.
Ensuring the use of approaches to ensure statistical validity such as a minimum number
of observations or minimum denominator for each measure.
Using methods for risk-adjustment to account for variation in both case-mix and severity
among providers of services and suppliers.
Identifying methods for handling outliers.
Correcting measurement errors and assessing measure reliability.
Identifying appropriate peer groups of providers and suppliers for meaningful
comparisons.

Describe the business model you will use that will cover the costs of performing the required functions.
Describe past experiences or future plans for successfully combining claims data from different payers
to calculate performance reports.
Describe past experiences or future plans for designing and continuously improving the format of
performance reports on providers of services and suppliers.
Describe past experiences or future plans for accurately preparing performance reports on providers of
services and suppliers and making performance report information available to the public in aggregate
form.
Describe past experiences or future plans for preparing understandable descriptions of the measures
used to evaluate the performance of providers of services and suppliers so that consumers, providers of

services and suppliers, health plans, researchers, and other stakeholders can assess performance
reports. If possible, please provide examples of such descriptions.
Describe past experiences or future plans for implementing and maintaining a process for providers of
services and suppliers to review reports prior to publication and providing a timely response to provider
of services and supplier inquiries regarding requests for data, error correction, and appeals.
Describe past experiences or future plans for establishing, maintaining, and monitoring a rigorous data
privacy and security program, including ensuring compliance with plans related to the privacy and
security of data, as well as training staff on the data privacy and security policies.
Claims data from other sources
Describe the claims data from other sources that you intend to combine with the Medicare data.
Provide a list of the sources of this other claims data.
Describe how the addition of your claims data from other sources addresses the methodological
concerns regarding the calculation of performance measures from a single payer source.
Data privacy and security policies
Provide documentation of your existing and/or planned data privacy and security policies, including
enforcement mechanisms.
Provide documentation of any current data security and privacy certifications held. Examples include
FISMA, or HIPAA (if you are a covered entity).
Operational Requirements: Measure calculations and performance reports
Provide a list of all measures you intend to calculate and report, including:
(A)
(B)
(C)
(D)

Name of the measure, and whether it is a standard or alternative measure,
Name of the measure developer/owner,
Measure specifications, including numerator and denominator,
The rationale for selecting each measure, including the relationship to existing
measurement efforts and the relevancy to the population in the geographic area(s) the
entity will serve, including:
(i)
(ii)

(E)

A specific description of the geographic area or areas it intends to serve, and
A specific description of how each measure evaluates providers of services and
suppliers on quality, efficiency, effectiveness, and/or resource use.

A description of the methodologies it intends to use in creating reports with respect to
all of the following topics:
(i)
(ii)

Attribution of beneficiaries to providers and/or suppliers,
Benchmarking performance data, including
(a)
methods for creating peer groups,

(iii)

(b)
justification of any minimum sample size determinations made, and
(c)
methods for handling statistical outliers.
Risk adjustment.

Provide a description of the process you will establish to allow providers of services and suppliers to
view reports confidentially, request data, and ask for the correction of errors before the reports are
made public.
Submit a prototype report and a description of your plans for making the reports available to the public.