CMS-10394 Revised QE Application

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

DRAFT QUALIFIED ENTITY APPLICATION

DISCLOSURE STATEMENT: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-xxxx. The time required to complete this infor­mation collection is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please 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 
City, State 		ZIP Code 
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 QUALIFIED ENTITY APPLICATION

This application provides an opportunity for eligible organizations to apply to serve as a qualified entity.

Due Date

TBD

Application Submission Process

TBD

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) Indentifying an appropriate method to attribute a particular patient’s services to specific providers of services and suppliers.

(B) Ensuring the use of approaches to ensure statistical validity such as a minimum number of observations or minimum denominator for each measure.

(C) Using methods for risk-adjustment to account for variation in both case-mix and severity among providers of services and suppliers.

(D) Identifying methods for handling outliers.

(E) Correcting measurement errors and assessing measure reliability.

(F) 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) Name of the measure, and whether it is a standard or alternative measure,

(B) Name of the measure developer/owner,

(C) Measure specifications, including numerator and denominator,

(D) 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:

1. A specific description of the geographic area or areas it intends to serve, and

(ii) A specific description of how each measure evaluates providers of services and suppliers on quality, efficiency, effectiveness, and/or resource use.

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

(i) Attribution of beneficiaries to providers and/or suppliers,

(ii) Benchmarking performance data, including

(a) methods for creating peer groups,

(b) justification of any minimum sample size determinations made, and

(c) methods for handling statistical outliers.

(iii) 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.