CMS-10394 QECP Data Source Attestation

OMB No. 0938-1144
Exp.
04/30/2015
Revised
3/26/2014

QECP DATA SOURCE ATTESTATION
Lead Entity Applying for Qualified Entity Certification Program (QECP)
Legal Name of Applying Entity
Trade Name/DBA
Name of Data Recipient
(if different from Applying Entity)
Complete the Provider Reporting Profile table once.

Provider Reporting Profile
1. For the provider types
(specified in Element 1C) in the
geographic region (specified in
Element 1B) you intend to
report, what proportion of
these practicing providers will
be included in your
performance reports?
2. Provide an estimate of all
covered lives (i.e., insuredcommercial, Medicaid,
Medicare Advantage, and
Medicare FFS) in the
geographic region you plan to
cover in your QE performance
reports.
3. Provide the total number of
covered lives included in all
claims data sources you will
obtain (i.e., the data from
which you pull data for
reporting, not the sum of the
measure denominators).

Total Number of Covered Lives in Geographic Coverage
Area:

(Please see Appendix A, Section 2 for instructions)

3a) Total Number of Covered Lives in Claims Data from
Data Suppliers (excluding Medicare FFS data):

3b) Total Number of Covered Lives in Medicare FFS data:

(Please see Appendix A, Section 1 for instructions)

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Hint: Unless your data sources will contain claims data on
all covered lives in the geographic coverage area, the sum
of questions 3a and 3b should be less than the number
reported for question 2.
4. Provide the range and average
number of covered lives per
provider on which you intend
to report (i.e., the provider in
the QE database for which you
have measures where that
type of provider is assessed,
not the sum of their measure
denominators).

Covered Lives Per Provider (excluding Medicare FFS
data):
Range (minimum and maximum) of covered lives:
Mean # of covered lives:
Covered Lives Per Provider (including Medicare FFS
data):
Range (minimum and maximum) of covered lives:
Mean # of covered lives:

Repeat the Data Supplier Profile table for each data supplier relevant to the applicant’s
Qualified Entity application and program.

Data Supplier Profile
Legal Name of Data Supplier
Trade Name/DBA
Effective Dates of Agreement
Contact Name
Contact Title
Contact Email
Street Mailing Address
Suite/Mail Stop
City, State, Zip
Phone
Fax
Website URL
Data Detail

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1. Volume of QE Data
(e.g., # of covered lives and claim lines)

Covered Lives:

Hint: The number of covered lives reported
for all individual data supplier profiles must Claim Lines:
add up to the number reported for
question 3a in the provider reporting
profile above.
List state(s) in which your data and reporting
cover the entire state:
List state(s) in which your data and reporting
cover only part of the state:

Geographic Coverage Area of Data
Received from Supplier to be Included in
QE Performance Reports

For partial covered states, list
Counties covered:
OR
MSAs covered:
OR
Other regional boundary:

Provider Types in Data Received from
Supplier to be Included in QE Performance
Reports (check all that apply):

QECP Data Source Attestation





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Physicians
Hospitals (excluding critical access)
Critical access hospitals
Skilled nursing facilities
Comprehensive outpatient rehabilitation
facilities
 Home health agencies
 Hospice programs
 Other
Specify:________________________

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Signatures
To the best of my knowledge and belief, all data in this attestation are true and correct. The
document has been authorized by the Qualified Entity Certification Program (QECP) Applicant
in reference to the QECP Applicant’s data supplier(s).
QECP Applicant
Authorized Representative Name (printed) ___________________________________________
Authorized Representative Title (printed) ____________________________________________
Signature_____________________________________________ Date ____________________
Phone _______________________________________

QECP Data Source Attestation

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RevisedOMB
3/24/2014
No. 0938-1144
Exp. 04/30/2015

Appendix A
1. How to Determine the Total Number of Covered Lives (Enrollment)
in the Medicare FFS Data for your QE Geographic Coverage Area
1.1 Medicare FFS Enrollment by State
a. Visit: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-andReports/MedicareEnrpts/Downloads/Sageall12.pdf
b. Obtain the state total from the first column ‘A and/or B.’ See screenshot below:

c. Obtain the Medicare Advantage penetration rate: http://kff.org/other/stateindicator/medicare-advantage-penetration/

Appendix A: How to Determine Covered Lives

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d.

To determine the number of Medicare FFS enrollees for an entire state (excluding Medicare
Advantage enrollees), adjust down the number obtained in Step 1.1.b by the percentage
obtained in Step 1.1.c. For example, Alabama FFS enrollment = 1,077,230 * (1 - 0.215) =
845,625

1.2 Medicare FFS Enrollment by County
a. Visit: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-andReports/MedicareEnrpts/Downloads/County2010.pdf
b. Use the total from the first section of columns ‘Hospital and/or Supplemental Medical.’ See
screenshot below:

c. Obtain Medicare Advantage enrollment by county, using the “Refine Results” toolbar on the
left-hand side of the screen: http://kff.org/medicare/state-indicator/total-enrollment-2/

d. To determine the number of Medicare FFS enrollees for a particular county (excluding Medicare
Advantage enrollees), subtract the number obtained in Step 1.2.c from the number obtained in
Step 1.2.b. For example, Cuyahoga, Ohio FFS enrollment = 223,806 – 83,265 = 140,541
1.3 Reporting Medicare FFS Enrollment in the 2013 Annual Report Workbook
Add together all Medicare FFS enrollees for the states and/or counties in your QE geographic
coverage area (i.e., Step 1.1.d + Step 1.2.d) and report as the response to Question 3b in the
Provider Reporting Profile of the Element 2A Data Source Attestation. This number is also
reported in Table 1, Question 2.a.ii, in the 2013 Annual Report Workbook.

Appendix A: How to Determine Covered Lives

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2. How to Determine the Total Number of Covered Lives in your QE
Geographic Coverage Area
a. Visit: http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml
b. Click on “Advanced Search”
c. Under “Topic or Table Name” enter: Health Insurance
d. Under State, county, or place, enter your geographic coverage area (i.e., state name or county
name). Do not enter more than one geographic area into the search at a time (i.e. several
counties).
e. Please use ID #2701, Health Insurance Coverage Status, 2012 ACS 1-year estimates. If, for some
counties, 2012 1-year estimates are not available, use 2012 ACS 3-year estimates. If neither 1or 3-year estimates are available, use 2012 ACS 5-year estimates.
f.

In order to determine the number of covered lives in the state or county, you will need to
subtract the number uninsured from the total population. See screenshot below:

g. Add together all covered lives in your geographic coverage area and report as the response to
Question 2 in the Provider Reporting Profile of the Element 2A Data Source Attestation. This
number is also reported in Table 1, Question 3, in the 2013 Annual Report Workbook.

Appendix A: How to Determine Covered Lives

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