Form CMS-10394 Application

APPENDIX B: PAPER-BASED QE APPLICATION FORM
PRA 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 0938-1144. The time required to complete this information collection is
estimated to average 500 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 comments concerning the accuracy of the time estimate(s) or suggestions for improving this form,
please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850. Please do not send applications, claims, payments, medical records
or any documents containing sensitive information to the PRA Reports Clearance Office. Please note
that any correspondence not pertaining to the information collection burden approved under the
associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If
you have questions or concerns regarding where to submit your documents, please
contact [email protected].

Instructions
Submit the completed QE application form and supporting documents electronically
to: [email protected]. Submit any questions to: [email protected].

Date Application
Submitted

Department of Health & Human Services
Centers for Medicare & Medicaid Services

Date Application
Received by CMS

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Section 1: General Information
Instructions: Please input the prospective applicant’s information. The listed trade name and
type of applicant should be for the lead applicant. Subcontractors or partners for this effort
should be listed in the Member Organizations field.
Applicant’s Trade Name/DBA
Type of Applicant
Profit Organization
Non-Profit Organization
Other (describe)
Applicant’s Employer ID Number
Name(s) of Contractor(s) or Member
Organization(s)
(Contact [email protected] to
obtain further instructions to submit
required contractor or member
organization information)

Data Recipient’s Name
Data Requested
Regional (specify States)
National

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Section 2: Mailing Address
Instructions: The mailing address should be an address where mail correspondence about the
application or program can be delivered.
Street Mailing Address __________________________________________________________
Suite/Mail Stop ________________________________________________________________
City _____________________________________ State ____________ ZIP Code ___________
Phone _______________________________________ Fax _____________________________
Website ______________________________________________________________________

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Section 3: Contact Information
Chief Executive Officer (or other equivalent executive)
Instructions: Please provide the contact information for the CEO, or equivalent executive, who
has the authority to oversee the entity’s application and QECP responsibilities.
Prefix _______
First Name____________________________________________________________________
Middle Initial ______
Last Name____________________________________________________________________
Degree ____________________
E-mail Address _________________________________________________________________
Street Mailing Address ___________________________________________________________
Suite/Mail Stop ________________________________________________________________
City _____________________________________ State ____________ ZIP Code ___________
Phone _______________________________________ Fax _____________________________
Point of Contact for Application
Instructions: Please provide the contact information for the individual who will be the primary
contact for day-to-day application and program correspondence.
Prefix _______
First Name____________________________________________________________________
Middle Initial ______
Last Name____________________________________________________________________
Degree ____________________
E-mail Address _________________________________________________________________
Street Mailing Address ___________________________________________________________
Suite/Mail Stop _________________________________________________________________
City _____________________________________ State ____________ ZIP Code ___________
Phone _______________________________________ Fax _____________________________

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Section 4: Standards
Instructions: Please indicate whether the entity is capable of supplying information with regard
to each element by checking the appropriate box (Yes, No, N/A). Using plain language, please
provide explanations in the “explanation of self-assessment” comment box.
Entities are required to submit supporting documentation to support their self-assessment and
for the purposes of the minimum requirements review and assessment. Please list the name of
the supporting document, its relevance to the element, and the pages within the document
that prove such relevance. Additional supporting documentation may be listed in Section 6 of
this application form. Refer to the QECP Operations Manual for complete program information,
including “example documentation” descriptions and “must include” instructions.

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STANDARD 1: APPLICANT PROFILE
Intent: A prospective QE must provide information about its organization and structure, the
types of providers it intends to evaluate, the geographic areas for which it intends to report
data, and its ability to meet financial requirements of the program.
Element 1A: Define applicant organization
Self assessment:

Assessment:
Applicant is a legally recognized “lead” entity, accountable to CMS for the
receipt of Medicare data, with clear contractual relationships identified and
documented between entities (when applicable) that make it possible for the
applicant to meet the QECP standards.

Yes
No

Explanation of Self-assessment:

Evidence:
The applicant’s incorporation, type of organization, and licensure, if applicable.
Contractors or member organizations working with the lead entity in support of its QECP
activities must also include incorporation, type of organization, and licensure information, as
well as evidence of a contractual relationship between the lead and other entities that includes
breach of contract liability with potential to collect damages for failure to perform.
Supporting Documentation:
Supporting documentation must include a completed QECP Letter of Commitment with
Contractual Relationship Attestation and CMS Quality Improvement Organization (QIO)
Attestation (where applicable).

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Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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Element 1B: Identify the geographic areas that applicant’s reports will cover
Self assessment:

Assessment:
Applicant defines the geographic area(s) in which performance reporting will
incorporate the Medicare data.

Yes
No

Explanation of Self-assessment:

Evidence:
1. Description of geographic area(s) by state for which the applicant requests Medicare data. If

a 5% national sample is requested, a justification for the request must be included.

Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
2. Description of geographic area(s) by state for which the applicant has claims data from

another payer source.

Supporting Documentation:

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Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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Element 1C: Identify the types of providers whose performance the applicant intends to
assess using Medicare data
Self Assessment:
assessment:
Applicant lists the types of providers for which it intends to evaluate
performance using Medicare and other claims data.

Yes
No

Explanation of Self-assessment:

Evidence:
List of types of providers to be covered in each geographic area report that uses Medicare data.
The types of providers must be those that submit claims, and are paid, for Medicare-covered
services and those for which the applicant has at least one additional source of claims data. The
following is a list of possible provider types as defined by the Social Security Act:
a. Physicians
b. Other health care practitioners
c. Hospitals
d. Critical access hospitals
e. Skilled nursing facilities
f. Comprehensive outpatient rehabilitation facilities
g. Home health agencies
h. Hospice programs
i. Other facilities or entities that furnish items or services
Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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Element 1D: Show ability to cover the costs of performing the required functions of a
qualified entity
Self Assessment:
assessment
:
Applicant’s business model is projected to cover the cost of public reporting, both
the cost of the data and the cost of developing the reports.

Yes
No

Explanation of Self-assessment:

Evidence:
Documentation of a program budget reviewed, approved, and signed by one of the applicant’s
senior executives. Evidence must come from the applicant, not from a member organization or
contractor.
Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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STANDARD 2: DATA SOURCES
Intent: A prospective QE must provide evidence of the ability to combine claims data from
other sources to calculate performance reports.
Element 2A: Obtain claims data from at least one other payer source to combine with
Medicare Parts A and B claims data, and Part D prescription drug event data
Self Assessment:
assessment:
For the geographic areas identified in Element 1B and for providers identified in
Element 1C, applicant possesses claims data from at least one other source;
however, obtaining claims data from two or more sources is preferable.

Yes
No
N/A

Explanation of Self-assessment:

Evidence:
An attestation from the entities from which the applicant obtains the claims data that will be
combined with the Medicare data. The attestation should include geographic area and types of
providers included in the data shared with the prospective QE.
Supporting Documentation:
Supporting documentation must include a completed QECP Data Source Attestation.
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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Element 2B: Accurately combine Medicare claims data with claims data from other payer
sources
Self Assessments:
assessment
s:
1. QE accurately combines Medicare claims data with claims data from at least
one other payer source.

Yes

2. QE demonstrates experience, generally 3 or more years, accurately
combining claims data from different payer sources.

Yes

No

No

Explanation of Self-assessments:

Evidence:
Evidence of experience submitted by the applicant may be the demonstrated experience of the
applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member
organization of the collaborative.
1.

Documented process used to combine Medicare claims data with other payer claims data
for the purposes of the QE's provider performance measurement. At a minimum, this must
include the QE's method for matching provider identifiers across different claims data
sources.

Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

2. Document(s) showing 3 years of experience aggregating claims data to produce at least two
performance measures.
Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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STANDARD 3: DATA SECURITY
Intent: A QE must submit documentation that describes the QE organizational environment.
The organizational environment includes all entities that will be working with or hosting CMS
data. The QE must provide data flow diagrams and business and service level agreements. The
QE must also provide evidence of rigorous data security and privacy policies and procedures
including enforcement mechanisms.
Element 3A (Administrative): Show ability to comply with Federal data security and privacy
requirements, and document a process to follow those protocols
Self Assessment:
assessment:
Applicant has established systems and protocols to address the following
security elements (as detailed in the CMS ARS):
 Audit and Accountability
 Security Authorization and Assessment
 Incident Response, including notifying CMS and beneficiaries of
Yes
inappropriate data access, violations of applicable Federal and state
No
privacy and security laws and regulations for the preceding 10-year
period (or, if the applicant has not been in existence for 10 years, the
length of time the applicant has been an organization), and any
corrective actions taken to address the issues
 Planning
 Risk Assessment
 Compliance with applicable state laws regarding privacy and security
Explanation of Self-assessment:

Evidence:
Evidence of experience submitted by the applicant may be the demonstrated experience of the
applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member
organization of the collaborative.

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1. Current assessments that show compliance with the CMS ARS at the moderate impact level.
If the applicant has not undergone any such assessments, it must produce documentation
of the systems and protocols that meet this same threshold with respect to the security
factors listed in Element 3A, which are further described below. If these systems and
protocols do not meet the standards of the ARS or have not yet been fully implemented,
the applicant may be placed under a SIP to correct the issue and progress tracked through
the plan of action and milestone (POAM) reporting process.
Audit and Accountability: Applicant must (i) create, protect, and retain information
system audit records to the extent needed to enable the monitoring, analysis,
investigation, and reporting of unlawful, unauthorized, or inappropriate information
system activity; and (ii) ensure that the actions of individual information system users
may be uniquely traced to those users so they can be held accountable for their actions.
Security Authorization and Assessment: Applicant must (i) periodically assess the
security controls in organizational information systems to determine if the controls are
effective in their application; (ii) develop and implement plans of action designed to
correct deficiencies and reduce or eliminate vulnerabilities in organizational information
systems; (iii) authorize the operation of organizational information systems and any
associated information system connections; and (iv) monitor information system
security controls on an ongoing basis to ensure the continued effectiveness of the
controls.
Incident Response: Applicant must (i) establish an operational incident handling
capability for organizational information systems that includes adequate preparation,
detection, analysis, containment, recovery, and user response activities; and (ii) track,
document, and report incidents to organizational officials and/or authorities.
Planning: Applicant must develop, document, periodically update, and implement
security plans for organizational information systems that describe the security controls
in place or planned for the information systems and the rules of behavior for individuals
accessing the information systems.
Risk Assessment: Applicant must periodically assess the risk to organizational operations
(including mission, functions, image, or reputation), organizational assets, and
individuals, resulting from the operation of organizational information systems and the
associated processing, storage, or transmission of organizational information.
Compliance with applicable state laws regarding privacy and security: Applicants,
regardless of Certification and Accreditation status, must document compliance with
applicable state laws regarding privacy and security.
Supporting Documentation:
Supporting documentation must include a completed QECP Data Security Workbook.

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Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
2. All applicants, regardless of Certification and Accreditation status, must document all
breaches of data security or privacy within the past 10 years (or the lifetime of the
organization if that is less than 10 years).
Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
3. All applicants, regardless of Certification and Accreditation status, must document the
protocols and systems that will be implemented for transferring information to providers as
part of the request for corrections and appeals process.
Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
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Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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Element 3B (Technical): Identify system users and prequalification process for access to data
Self assessment:

Assessment:
Applicant has established systems and protocols to address the following
security elements (as detailed in the CMS ARS):
1.
2.
3.
4.
5.

Access Control
Awareness and Training
Configuration Management
Identification and Authentication
Personnel Security

Yes
No

Explanation of Self-assessment:

Evidence:
Evidence of experience submitted by the applicant may be the demonstrated experience of the
applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member
organization of the collaborative.
Current security assessments demonstrating compliance with the CMS ARS at the moderate
impact level. If the applicant has not undergone any such assessments, it must produce
documentation of the systems and protocols in place with respect to the security factors listed
in Element 3B and further described below. If these systems and protocols do not meet the
standards of the ARS or have not yet been fully implemented, the applicant may be placed
under a SIP to correct the issue, with progress tracked through the POAM reporting process.
Access Control: Applicant must limit information system access to authorized users,
processes acting on behalf of authorized users, or devices (including other information
systems) and to the types of transactions and functions that authorized users are
permitted to exercise.
Awareness and Training: Applicant must (i) ensure that managers and users of
organizational information systems are made aware of the security risks associated with
their activities and of the applicable laws, Executive Orders, directives, policies,
standards, instructions, regulations, or procedures related to the security of
organizational information systems; and (ii) ensure that organizational personnel are
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adequately trained to carry out their assigned information security-related duties and
responsibilities.
Configuration Management: Applicant must (i) establish and maintain baseline
configurations and inventories of organizational information systems (including
hardware, software, firmware, and documentation) throughout the respective system
development life cycles; and (ii) establish and enforce security configuration settings for
information technology products employed in organizational information systems.
Identification and Authentication: Applicant must identify information system users,
processes acting on behalf of users, or devices and authenticate (or verify) the identities
of those users, processes, or devices, as a prerequisite to allowing access to
organizational information systems.
Personnel Security: Applicant must (i) ensure that individuals occupying positions of
responsibility within organizations (including third-party service providers) are
trustworthy and meet established security criteria for those positions; (ii) ensure that
organizational information and information systems are protected during and after
personnel actions such as terminations and transfers; and (iii) employ formal sanctions
for personnel failing to comply with organizational security policies and procedures.
Supporting Documentation:
Supporting documentation must include a completed QECP Data Security Workbook.
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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Element 3C (Physical): Identify processes and systems in place to protect the IT physical
infrastructure
Self Assessment:
assessment:
Applicant has established systems and protocols to address the following
security elements (as detailed in the CMS ARS):
1.
2.
3.
4.
5.
6.
7.

Contingency Planning
Maintenance
Media Protection
Physical and Environmental Protection
System and Services Acquisition
System and Communications Protection
System and Information Integrity

Yes
No

Evidence:
Evidence of experience submitted by the applicant may be the demonstrated experience of the
applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member
organization of the collaborative.
Current security assessments demonstrating compliance with the CMS ARS at the moderate
impact level. If the applicant has not undergone any such assessments, it must produce
documentation of the systems and protocols in place with respect to the security factors listed
in Element 3C and described further below. If these systems and protocols do not meet the
standards of the ARS or have not yet been fully implemented, the applicant may be placed
under a SIP to correct the issue, with progress tracked through the POAM reporting process.
Contingency Planning: Applicant must establish, maintain, and effectively implement
plans for emergency response, backup operations, and post-disaster recovery for
organizational information systems to ensure the availability of critical information
resources and continuity of operations in emergency situations.
Maintenance: Applicant must (i) perform periodic and timely maintenance on
organizational information systems; and (ii) provide effective controls on the tools,
techniques, mechanisms, and personnel used to conduct information system
maintenance.
Media Protection: Applicant must (i) protect information system media, both paper and
digital; (ii) limit access to information on information system media to authorized users;
and (iii) sanitize or destroy information system media before disposal or release for
reuse.
Physical and Environmental Protection: Applicant must (i) limit physical access to
information systems, equipment, and the respective operating environments to

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authorized individuals; (ii) protect the physical plant and support infrastructure for
information systems; (iii) provide supporting utilities for information systems; (iv)
protect information systems against environmental hazards; and (v) provide
environmental controls in facilities containing information systems.
System and Services Acquisition: Applicant must (i) allocate sufficient resources to
adequately protect organizational information systems; (ii) employ system development
life cycle processes that incorporate information security considerations; (iii) employ
software usage and installation restrictions; and (iv) ensure that third-party providers
employ adequate security measures to protect information, applications, and/or
services outsourced from the organization.
System and Communications Protection: Applicant must (i) monitor, control, and
protect organizational communications (i.e., information transmitted or received by
organizational information systems) at the external boundaries and key internal
boundaries of the information systems; and (ii) employ architectural designs, software
development techniques, and systems engineering principles that promote effective
information security within organizational information systems.
System and Information Integrity: Applicant must (i) identify, report, and correct
information and information system flaws in a timely manner; (ii) provide protection
from malicious code at locations within organizational information systems; and (iii)
monitor information system security alerts and advisories and take actions in response.
Supporting Documentation:
Supporting documentation must include a completed QECP Data Security Workbook.
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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STANDARD 4: METHODOLOGY FOR MEASUREMENT AND ATTRIBUTION
Intent: A prospective QE must provide evidence of its ability to accurately calculate quality and
efficiency, effectiveness, or resource use measures from claims data for measures it intends to
calculate with Medicare data. See the Operations Manual for additional information.
Element 4A: Follow measure specifications
Self assessment:

Assessment:
QE uses measure specifications accurately for selected measures, including
numerator and denominator inclusions and exclusions, measured time periods,
and specified data sources.

Yes
No

Explanation of Self-assessment:

Evidence:
For the measures listed in Elements 5A and 5B, the QE must supply the measure specifications
through a hyperlink to the original specification, a URL, or a copy of the specifications.
For the measures listed in Elements 5A and 5B, the QE must supply the measure’s clinical and
construction logic (e.g., numerator and denominator eligibility criteria,exclusions, temporal
parameters), and data sources that align with the measure specifications.
Supporting Documentation:

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Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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Element 4B: Use a defined and transparent method for attribution of patients and episodes
Self assessment
s:

Assessments:
1. QE applies an appropriate method to attribute a particular patient's services
or episode to specific providers.

Yes

2. QE demonstrates experience, generally 3 or more years, accurately
attributing patient's services or episode to specific providers.

Yes

No

No

Explanation of Self-assessments:

Evidence:
Evidence of experience submitted by the applicant may be the demonstrated experience of the
applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member
organization of the collaborative.
1. Methodology paper or document defining how the QE attributes patient services or
episodes to specific providers. If the attribution methods are different for different types of
providers (or measures), the QE must describe each methodology.
Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
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Relevant Pages: _____________________________________________________________
2. Methodology paper or document describing attribution approaches the QE has defined and
executed over the past 3 years. Note that if the attribution methodology has changed over
the past 3 years, the QE must provide a rationale for the change.
Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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Element 4C: Set and follow requirements to establish statistical validity of measure results for
quality measures
Self Assessments:
assessment
s:
1. For reporting quality measures using Medicare data, QE uses only measures
Yes
with at least 30 observations, or the calculated confidence interval is at least
No
90%, or the measure reliability is at least 0.70.
2. QE demonstrates experience, generally 3 or more years, producing quality
measures with statistical validity.

Yes
No

Explanation of Self-assessments:

Evidence:
Evidence of experience submitted by the applicant may be the demonstrated experience of the
applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member
organization of the collaborative.
1. Methodology paper or document stating the QE's minimum requirements for reporting a
quality measure that incorporates any of the received Medicare data. This includes one of
the following: minimum sample size (or denominator size) requirements, minimum
calculated confidence interval, or minimum reliability score requirements.
Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3

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Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
2. For each quality measure for which the QE incorporates the Medicare FFS data, the QE must
submit one of the following: sample size, reliability score, or confidence interval that will be
used in reporting. Evidence supporting these statements must be submitted.
Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
3. Document(s) showing the QE’s requirements for establishing statistical validity for quality
measures included in previous performance reporting efforts, together with examples of
how the QE has applied these requirements over the past 3 years for at least two quality
measures. If any of the selected quality measures require the application of distinct or
different statistical thresholds, then these must also be submitted.
Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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Element 4D: Set and follow requirements to establish statistical validity of measure results
for efficiency, effectiveness, and resource use measures
Self Assessments:
assessment
s:
Yes
1. For selected efficiency, effectiveness, and resource use measures using
Medicare data, QE uses only measures for which reliability and validity is
No
demonstrated.
N/A
Yes
2. For selected efficiency, effectiveness, and resource use measures using
Medicare data, that specify the use of a standardized payment or pricing
approach, the specified standardized payment methodology is used.

3. QE demonstrates experience, generally 3 or more years, producing
efficiency, effectiveness, and resource use measures with statistical validity.

No

N/A
Yes
No

N/A
Applicants are only required to submit evidence for Element 4D if they select efficiency,
effectiveness, or resource use measures to evaluate providers.
Explanation of Self-assessments:

Evidence:
Evidence of experience submitted by the applicant may be the demonstrated experience of the
applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member
organization of the collaborative.
1. Methodology paper that states the QE's minimum requirements for reporting a measure
with combined data. This includes the minimum calculated confidence interval or the
reliability score.
Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
2. For each efficiency, effectiveness, and resource use measure for which the QE incorporated
Medicare data, the QE must submit sample size requirements, actual sample size, and one
of the following: reliability score or confidence interval that will be used in reporting.
Evidence supporting these statements must be submitted.
Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
3. Description of the standard payment methodology implemented for applicable measures
included in the QE’s QE performance reports.
Supporting Documentation:

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Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
4. Document(s) showing the QE’s requirements for establishing statistical validity for
efficiency, effectiveness, and resource use measures included in previous performance
reporting efforts, together with examples of how the QE has applied them over the past 3
years for each selected type of measure (efficiency, effectiveness, and resource use). If any
of the efficiency, effectiveness, and resource use measures require the application of
distinct or different statistical thresholds, then these must also be submitted.
Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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Element 4E: Use appropriate methods to employ risk adjustment
Self assessment
s:

Assessments:
1. QE provides a rationale for using, or not using, a risk adjustment method for
each selected measure. Furthermore, the QE provides a description of the
risk adjustment method for each applicable measure.
2. QE demonstrates experience, generally 3 or more years, applying risk
adjustment if any of the selected measures require a risk adjustment
approach.

Yes
No
N/A
Yes
No
N/A

Qualified entities are only required to submit evidence for Element 4E if they select a measure(s)
that specifies a risk adjustment method.
Explanation of Self-assessments:

Evidence:
Evidence of experience submitted by the applicant may be the demonstrated experience of the
applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member
organization of the collaborative.
1. Methodology paper indicating for each measure for which the QE incorporated Medicare
data:
a. How the QE determined whether risk adjustment was necessary
b. The explicit methodology used for risk adjustment, including any case-mix or
severity adjustment
c. A justification if the QE determined that risk adjustment was not necessary.
Supporting Documentation:

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Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
2. Document(s) showing consideration of risk adjustment, use of risk-adjustment
methodologies, and/or justification for not using risk adjustment over the past 3 years in
previous performance reports.
Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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Element 4F: Use appropriate methods to handle outliers
Self assessments:

Assessments:
1. QE describes its outlier method (i.e., how to identify and account for
outliers) for each selected measure as applicable.

Yes

2. QE demonstrates experience, generally 3 or more years, applying relevant
outlier methods, as applicable.

Yes

No

No

Explanation of Self-assessments:

Evidence:
Evidence of experience submitted by the applicant may be the demonstrated experience of the
applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member
organization of the collaborative.
1. Methodology paper indicating for each measure for which the QE incorporated Medicare
data:
a. Rationale for using, or not using, an outlier method.
b. Detailed description of outlier method; specifically, how outliers were identified
(e.g., more than 3 standard deviations from the mean) and how outliers were
accounted for (e.g., truncation or removal of outlier).
Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
2. Document(s) showing identification of outliers, use of outlier methods, or justification for
not using outlier methods over the past 3 years in previous performance reports, for each
type of measure.
Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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Element 4G: Use comparison groups when evaluating providers compared to each other
Self assessments:

Assessments:
1. QE defines the comparison groups it uses to report results for each selected
measure.

Yes

2. QE demonstrates experience, generally 3 or more years, selecting relevant
comparison groups (i.e., peer groups) for selected measures.

Yes

No

No

Explanation of Self-assessments:

Evidence:
Evidence of experience submitted by the applicant may be the demonstrated experience of the
applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member
organization of the collaborative.
1 Description of the comparison or peer groups used to evaluate performance for each
measure selected. Peer group identification includes each type of provider to be reported
on, including:
a. How the peer group was identified (external data source, provider-reported
specialty, Tax ID number)
b. Defined algorithms to identify relevant peer groups for measurement
c. Geographic parameters to correctly compare providers to their peers.
Supporting Documentation:

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Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
2. Document(s) showing the peer groups to which providers have been assigned, and how
peer groups have been defined in previous performance reports, during the past 3 years.
Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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Element 4H: Use benchmarks when evaluating providers
Self assessment
s:

Assessments:
1. QE defines the benchmarks it uses to report results for each selected
measure.

Yes

2. QE demonstrates experience, generally 3 or more years, comparing measure
results with benchmarks.

Yes

No
No

Explanation of Self-assessments:

Evidence:
Evidence of experience submitted by the applicant may be the demonstrated experience of the
applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member
organization of the collaborative.
1. Description of the benchmark selection process and any performance standard that is used.
The benchmark selection process includes:
a. How the benchmark is identified or estimated (external data source, current data
set)
b. Type of benchmark (90th percentile, national average, regional average)
c. Geographic parameters to correctly identify the benchmark if relevant (provided
region assignment uses regional benchmarks)
Supporting Documentation:

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Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
2. Document(s) showing the comparison of performance results of providers with benchmarks
during the past 3 years.
Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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STANDARD 5: MEASURE SELECTION
Intent: A prospective QE must provide documentation for each selected standard or alternative
measure used in public reporting to demonstrate its validity, reliability, responsiveness to
consumer preferences, and applicability. See the Operations Manual for additional information.
Element 5A: Use standard measures
Self assessment:

Assessment:
QE selects standard measures for which it incorporates Medicare data.

Yes
No

Explanation of Self-assessment:

Evidence:
List of selected standard measures for QE performance reporting. A description of each
measure including:
a. Name of measure.
b. Name of measure steward/owner.
c. Measure description.
d. Type of provider to which the QE applied the measure.
e. Rationale for selecting the measure, including the relationship of the measure to
existing measurement efforts and the relevance to the population in the geographic
area defined under Element 1B.
Supporting Documentation:
Supporting documentation must include a completed QECP Measure Information Workbook.
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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Element 5B: Use approved alternative measures
Self assessment
s:

Assessments:
1. QE proposes alternative measure for which it incorporates Medicare data.
Composite measures are considered alternative measures, even if they
composite or combine standard measures, unless the standard measure
itself is a composite.

Yes
No
N/A

2. QE demonstrates the measure is more valid, reliable, responsive to
consumer preferences, cost-effective, or relevant to dimensions of quality
and resource use not addressed by a standard measure, through
consultation and agreement with stakeholders in QE’s community or through
the notice and comment rulemaking process.
Qualified entities are only required to submit evidence for Element 5B if they
alternative measure to evaluate providers.

Yes
No
N/A
select an

Explanation of Self-assessments:

Evidence:
1.

List of selected alternative measures for QE performance reporting. A description of each
measure including:
a. Name of measure.
b. Name of measure steward/owner.
c. Measure description.
d. Type of provider to which QE applied the measure.
e. Evidence that the measure is more valid, reliable, responsive to consumer
preferences, cost-effective, or relevant to dimensions of quality and resource use not
addressed by a standard measure.
f. Rationale for selecting the measure, including the relationship of the measure to
existing measurement efforts and the relevance to the population in the geographic
area defined under Element 1B.
g. Process to monitor and evaluate if new scientific evidence is released or a related
standard measure is endorsed. If new evidence or a standard measure is available,

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the QE must notify CMS (QECP team) and submit all the new evidence. The QE must
start using the new standard measure within 6 months, or the QE may request, with
supporting scientific documentation, approval to continue using the alternative
measure.
Supporting Documentation:
Supporting documentation must include a completed QECP Measure Information Workbook.
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Documentation of consultation and agreement with stakeholders in the QE’s community,
together with a description of the discussion about the proposed alternative measure, including
a summary of all pertinent arguments supporting and opposing the measure or documentation
of notice and comment rulemaking process approval.
Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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STANDARD 6: VERIFICATION PROCESS
Intent: A prospective QE must provide evidence of a continuous process to correct
measurement errors and assess measure reliability. See the Operations Manual for additional
information.
Element 6A: Systematically evaluate accuracy of the measurement process, and correct errors
Self assessment:

Assessment:
QE demonstrates experience, generally 3 or more years, defining and verifying
its measurement and reporting processes, including the correction of errors and
updating of performance reports.

Yes
No

Explanation of Self-assessment:

Evidence:
Evidence of experience submitted by the applicant may be the demonstrated experience of the
applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member
organization of the collaborative.
1. Internal verification, audit process, or software used to evaluate the accuracy of calculating
performance measures from claims data.
Supporting Documentation:
Supporting documentation must include a completed QECP Measure Production Quality
Assurance (QA) Worksheet.
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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2. Name, credentials, and title of staff responsible for verifying the measurement process.
Supporting Documentation:
Supporting documentation must include a completed QECP Measure Production Quality
Assurance (QA) Worksheet.
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
3. Process for correcting errors.
Supporting Documentation:
Supporting documentation must include a completed QECP Measure Production Quality
Assurance (QA) Worksheet.
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
4. Process for updating reports to providers and consumers.
Supporting Documentation:
Supporting documentation must include a completed QECP Measure Production Quality
Assurance (QA) Worksheet.

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Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
5. Reports generated by the validation process.
Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
6. If using an external vendor, documentation of agreement and/or purchase order of the
software and/or systems vendor utilized in the QE's validation process.
Supporting Documentation:

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Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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7. Document(s) showing QE has 3 years of experience in evaluating the accuracy of the
measurement process and correcting errors covering all relevant areas.
Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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STANDARD 7: REPORTING OF PERFORMANCE INFORMATION
Intent: A prospective QE must demonstrate substantial experience and expertise in the design
and dissemination of performance reports, as well as the capacity and commitment to
continuously improve the reporting process. See the Operations Manual for additional
information.
Element 7A: Design reporting for providers and the public
Self assessments:

Assessments:
1. QE designs public and provider reporting to be produced using Medicare

data, including understandable descriptions of measures used.

2. QE plans dissemination of information to users at least annually.

Yes
No
Yes
No

Explanation of Self-assessments:

Evidence:
1. List of types of providers in each geographic area to be covered by QE performance

reporting.

Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
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Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
2. If measure calculations are aggregated or used to calculate provider ratings (e.g., a star

rating approach), a detailed description of the rating approach(es), including rating
calculation, measure results, and statistical methods used.

Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
3. QE performance report(s), including all items of information for the providers as they will be
displayed, including level of reporting and any rating approaches (such as number of stars)
to display performance. The report(s) must clearly explain the performance results or
ratings. All reports must be submitted if they are different (e.g., the provider report and the
public report ). QE performance report(s) must further demonstrate:
a. An indication, for each item reported, whether or not it was calculated in any part
with Medicare data.
b. An understandable description of the measures used to evaluate the performance of
providers so that consumers, providers, health plans, researchers, and other
stakeholders can assess performance reports.
c. Reporting at the provider level, or at a higher, more aggregated level (consistent with
measure specifications).
d. Display of measures in dispute (per provider).

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Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
4. Dissemination plans to inform all intended audiences of the existence of the QE
performance reports, including how to locate the reports.
Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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Element 7B: Improve reporting
Self assessment:

Assessment:
QE demonstrates experience, generally 3 or more years, designing and
continuously improving public reporting on health care quality, efficiency,
effectiveness, or resource use.
Explanation of Self-assessment:

Yes
No

Evidence:
Evidence of experience submitted by the applicant may be the demonstrated experience of the
applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member
organization of the collaborative.
Document(s) showing results of previous evaluation of reporting for the past 3 years, such as
testing with users and use of evaluations to improve reporting.
Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

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STANDARD 8: REQUESTS FOR CORRECTIONS OR APPEALS
Intent: A prospective QE must provide evidence of implementing and maintaining an
acceptable process for providers identified in a report to review the report prior to publication
and providing a timely response to provider inquiries regarding requests for data, error
correction, and appeals.
Element 8A: Use corrections process
Self assessment:

Assessment:
QE has established a process to allow providers to view reports confidentially,
request data, and ask for correction of errors before the reports are made
public.

Yes
No

Explanation of Self-assessment:

Evidence:
Evidence of experience submitted by the applicant may be the demonstrated experience of the
applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member
organization of the collaborative.
Process by which the QE will share relevant information about anticipated public reporting on a
provider with that provider at least 60 calendar days prior to publicly reporting results. QE
demonstrates experience, generally 3 or more years, including sharing:
a) Selected measures on which the provider is being measured.
b) Rationale for use.
c) Measurement methodology.
d) Data specifications and limitations.
e) Measure results for the provider.
f) Anticipated date for publishing reports for the public.
g) Description of the ongoing process by which providers may:
i.
Request additional information or data
ii.
Request corrections or changes prior to public reporting.

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Exp. 04/30/2015

Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

Department of Health & Human Services
Centers for Medicare & Medicaid Services

B-56

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Exp. 04/30/2015

Element 8B: Use secure transmission of beneficiary data
Self assessment:

Assessment:
QE has established a process that applies privacy and security protections to the
release of beneficiary identifiers and/or claims data to providers for the
purposes of the requests for corrections/appeals process.

Yes
No

Explanation of Self-assessment:

Evidence:
Description of process ensuring that only the minimum necessary beneficiary identifiers and/or
claims data will be disclosed in the event of a request by a provider, including the method for
secure transmission and the entity responsible for secure transmission.
Supporting Documentation:
Document 1
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 2
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________
Document 3
Document Name: ___________________________________________________________
Document Relevance: ________________________________________________________
Relevant Pages: _____________________________________________________________

Department of Health & Human Services
Centers for Medicare & Medicaid Services

B-57

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Section 5: Attestation
Instructions: Prior to an application being submitted as final, the contents of the application
must be accompanied with a completed attestation from an individual at the entity authorized
to attest to its accuracy and completion.
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
awarded.
Authorized Representative’s Name (printed) _________________________________________
Authorized Representative’s Title (printed) __________________________________________
Signature_____________________________________________ Date ____________________
Phone _______________________________________ Fax _____________________________

Department of Health & Human Services
Centers for Medicare & Medicaid Services

B-58

OMB No. 0938-1144
Exp. 04/30/2015

Section 6: Additional Supporting Documentation
Instructions: Please describe all additional supporting documentation submitted in conjunction
with this application that is not listed in Section 4.
1.

Standard:
_____________
Element:
_____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

2.

Standard:
_____________
Element:
_____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

3.

Standard:
_____________
Element:
_____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

4.

Standard:
_____________
Element:
_____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

5.

Standard:
_____________
Element:
_____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

6.

Standard:
_____________
Element:
_____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Exp. 04/30/2015

7.

Standard:
_____________
Element:
_____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

8.

Standard:
_____________
Element:
_____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

9.

Standard:
_____________
Element:
_____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

10.

Standard:
_____________
Element:
_____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

11.

Standard:
_____________
Element:
_____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

12.

Standard:
_____________
Element:
_____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

13.

Standard:
_____________
Element:
_____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

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Centers for Medicare & Medicaid Services

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14.

Standard:
_____________
Element:
_____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

15.

Standard:
_____________
Element:
_____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

Department of Health & Human Services
Centers for Medicare & Medicaid Services

B-61

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Exp. 04/30/2015