Application and Re-application processes

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

[MONTH DD, YYYY]
[CONTACT]
[ENTITY]
[ADDRESS]
[CITY, STATE]

[ZIP]

VIA EMAIL: [E-MAIL ADDRESS]
Niall Brennan
Director, Offices of Enterprise Management
Centers for Medicare & Medicaid Services
200 Independence Ave., S.W
Mail stop: 337D
Washington, DC 20001
Dear Niall:
This letter outlines the understanding between the Centers for Medicaid & Medicare Services
(CMS) and [ENTITY]
with regard to
[ENTITY]’s
intent to complete
the Qualified Entity Certification Review for the remaining minimum requirements:
 Ensuring data security (QECP Standard 3)
 Combining data sources (QECP Standard 2B)
 Measurement methodology (QECP Standard 4)
 Measure selection (QECP Standard 5)
 Verification process (QECP Standard 6)
 Reporting (QECP Standard 7)
 Provider corrections and appeals (QECP Standard 8)
Once CMS determines that Standard 3 is sufficiently met, we will request and obtain a QE Data
Use Agreement (DUA) and the Medicare Parts A and B claims data or Part D prescription drug
event (PDE) data we intend to use for the performance reports.
Further, [ENTITY]
agrees to complete the remaining minimum requirements listed in this document and, if CMS
deems sufficient, publicly release a QE provider performance report within 12 months of
receipt of the Medicare data received under the QE DUA (as proposed in Attachment A).
We acknowledge that CMS has determined that we have sufficiently:
1. Completed and attached evidence in the QECP Portal for Standards 1 (all Elements) and
Standard 2 (Element 2A only)

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2. Attested to the ability to meet all standards by marking “MET” or “UNMET” in the our
QECP secure application portal for each Element’s self-assessment
3. Signed and submitted our Letter of Commitment, which includes:
a. Proposed timeline for completing remaining Standard requirements and public
reporting—Attachment A
b. Contractual Relationship Attestation—Attachment B
c. QIO Attestation—Attachment C (if applicable)
Data will be distributed to [ENTITY]
upon successful completion of Standard 3 (Data Security), CMS approval of submitted QE DUA
materials, and payment of appropriate fees for the QE Medicare data. [ENTITY]
may not distribute reports containing Medicare claims data provided under this program until
the QECP team has reviewed [ENTITY]
compliance with all of the program requirements. Upon Review, if [ENTITY]
does not demonstrate compliance with QECP requirements, CMS reserves the right to retract
QE Certification and require [ENTITY]
to destroy or return Medicare data.
Included as part of this letter are: Attachment A: Proposed Timeline for QECP Compliance and
Public Reporting; Attachment B: Contractual Relationship Attestation; and Attachment C: QIO
Attestation (if applicable).
If the terms of this understanding are acceptable to [ENTITY]
, please acknowledge your agreement below and upload an executed copy of this letter to the
entity’s secure application portal.
ACCEPTED:
Name of Applicant Entity
Address of Applicant Entity
Telephone Number
Signature of Authorized Officer

Date

Name and Title of Authorized Officer

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Exp. 04/30/2015

Attachment A: [ENTITY]’s
Proposed Timeline for QECP Compliance and Public Reporting
Milestone

Weeks from Phase 1
Certification
(example)

Phase 2 Evidence Approved*
 Standard 3
QE DUA (and optional Research DUA) Completed
Data Payment Made
QE Medicare data received

Weeks from Phase 1
Certification
(to be completed by
applicant)

24
32
34
38-40
Weeks from Receipt
of QE Medicare Data
(example)

Milestone
Phase 3 Evidence Approved*
 Standard 2B
 Standard 4
 Standard 5
 Standard 6
 Standard 7
 Standard 8
Initiation of Provider Corrections and Appeals Process
(required 60 days before public report)
First Public Report Released

Weeks from Receipt
of QE Medicare Data
(to be completed by
applicant)

0–38

42
52

*Note: The time frame allotted for Phase 2 and Phase 3 evidence approval includes the time the QE
requires to assemble and submit required evidence, AND the time the QECP team requires to review
the submitted evidence. QEs will work with their Program Managers to schedule Phase 2 and Phase 3
reviews.

A-1

Attachment B: [ENTITY]’s
Contractual Relationship Attestation

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

CONTRACTUAL RELATIONSHIP ATTESTATION

Lead and Contractor or Member Organizations
Legal Name of Lead Entity
Trade Name/DBA
Name(s) of Contractor or
Member Organizations
(if applicable)
Does any organization on your
team (Lead or Other) also hold a
QIO contract with CMS?

 Yes
List Organization(s):

(If yes, complete Attachment C –
QIO Attestation)

 No

Repeat the following two tables for each Contractor or Member Organization relevant to the applicant’s
Qualified Entity application and program.

Attestation of Agreement with Contractor or Member Organization
Legal Name of Contractor or Member
Organization
Trade Name/DBA
Description of Contractual Relationship
General description of agreements in
place between the lead entity and other
contractor or member organizations (as
applicable)

Effective dates on agreement

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Exp. 04/30/2015

Attachment B: [ENTITY]’s
Contractual Relationship Attestation
The partner noted above will be
responsible for or involved in meeting
compliance for the following QECP
Standards:

Affirmation Statements
The lead entity must attest to the following statements with regard to each Contractor or
Member Organization (as applicable) by answering each statement.
STATEMENT

YES

NO

Contractor or Member Organization is willing to sign a Qualified
Entity Certification Program (QECP) Data Use Agreement (DUA).
Contractor or Member Organization understands that it will also
be subject to CMS review as part of the QECP and its actions may
result in sanctions and/or termination of the Qualified Entity.
Lead and Contractor or Member Organization have a legally
enforceable agreement in place that includes breach-of-contract
liability if one of the members of the group fails to deliver and
there would be the potential of collecting damages for that
failure to perform.
Signature
To the best of my knowledge and belief, all data in this attestation are true and correct, the
document has been authorized by the governing body of the lead applicant, and the lead
applicant will comply with the terms and conditions of the award and applicable Federal
requirements.
Authorized Representative Name (printed) ___________________________________________
Authorized Representative Title (printed) ____________________________________________

Signature_____________________________________________ Date ____________________
Phone______________________________________

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Attachment C: Quality Improvement Organization (QIO) Attestation

CMS QUALITY IMPROVEMENT ORGANIZATION ATTESTATION
An entity that holds a QIO contract with CMS is permitted to function as a QE, or as part of a QE
team, under the following conditions:
 the entity may not represent the fact that they are a QIO while conducting QE activities;
 any resources, both financial and operational, funded by CMS as part of the QIO
contract may not be used to sustain the entity’s QE program in any way;
 the entity must continue to uphold all terms of their QIO contract, including their
confidentiality and conflict of interest contractual obligations. The entity may wish to
request a conflict of interest determination by the CMS Office of Acquisitions and Grants
Management; and
 the entity must complete an attestation during Phase 1 of the QECP Minimum
Requirements Review attesting that they will adhere to the three conditions listed
above.
The table and signature section below must be completed by an authorized representative for
each entity in your QE team that holds a QIO contract with CMS. If none, you are not required
to submit Attachment C.
QIO Demographics
Name of Entity Recognized as a QIO (lead
applicant or partner/collaborator as part of
the QE team)
State(s) for which Entity Functions as a QIO
QIO Contact within the Entity
(name, title, email address, phone number)
QIO Contact within CMS
(name, title, email address, phone number)
QIO Affirmation Statements
We agree to maintain distinct and separate representation between QE and QIO
activities. We will not represent QE work or resulting products to be a function of
our QIO contract with CMS.

 Yes
 No

We agree to maintain funding for QE activities separate from QIO funding CMS
sources. Funds or resources provided by CMS to support the QIO program will not
be used or spent for the QE program, including funds or resources for operating
the QIO Standard Data Processing Systems (SDPS). QE-obtained Medicare data

 Yes
 No

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Attachment C: Quality Improvement Organization (QIO) Attestation
will not be stored on the SDPS.

If approved as a Certified QE (or a member of a Certified QE team), we agree to
uphold all terms of our QIO contract, including confidentiality and conflict of
interest contractual obligations. We understand that, per our request, a QE/QIO
conflict of interest analysis can be performed by CMS-OAGM.

 Yes
 No

Signature
To the best of my knowledge and belief, all information in this attestation is true and correct;
the document has been authorized by the governing body of the entity mentioned on page C-1;
and the entity will comply with all terms and conditions of the affirmation statements
mentioned on pages C-1 through C-2.

(Authorized Representative for QIO and QE Applicant Entity)
Name (printed) ___________________________________________
Title (printed) ____________________________________________
Email Address (printed) ___________________________________

Signature_____________________________________________ Date ____________________
Phone______________________________________

C-2