CAHPS for MIPS Group Registration

Quality Payment Program

2018 Registration Guide for the CMS Web Interface and CAHPS for MIPS Survey

Table of Contents

Section	Page Number
I. Introduction	2
II. Getting Started	3
III. Submit a New 2018 Registration for the CMS Web Interface and/or CAHPS for MIPS Survey Registration	5
IV. Modify an Existing 2018 Registration for the CMS Web Interface and/or CAHPS for MIPS Survey Interface Registration	7
V. View a CMS Web Interface and/or CAHPS for MIPS Survey Registration Summary	8
VI. Cancel Your 2018 Registration for the CMS Web Interface and/or CAHPS for MIPS Survey	9

1. Introduction

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) replaced a patchwork collection of reporting programs with a single system where Medicare physicians and clinicians have a chance to be rewarded for better care. There are two paths in this program:

• Merit-based Incentive Payment System (MIPS)

• Advanced Alternative Payment Models (APMs)

Historically, under the Physician Quality Reporting System (PQRS), groups were required to register to participate in the PQRS Group Practice Reporting Option (GPRO) utilizing one of the available submission mechanisms: Qualified Registry, Electronic Health Record (EHR) (via Direct EHR using certified EHR technology (CEHRT) or CEHRT via Data Submission Vendor), Qualified Clinical Data Registry (QCDR), and CMS Web Interface (for groups with 25 or more eligible professionals only), as well as groups that intended to administer the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for PQRS survey.

Now that the PQRS is sun-setting in 2018 and being replaced with the Quality Payment Program, groups participating in the Merit-based Incentive Payment System (MIPS) are not required to register, except for groups of 25 or more clinicians that intend to utilize the CMS Web Interface and/or administer the CAHPS for MIPS survey. Additionally, if you are participating in a Medicare Accountable Care organization (ACO), your ACO is required to submit quality data to CMS on your behalf and you do not need to create an EIDM account.

A “group” is defined as a single Medicare billing Taxpayer Identification Number (TIN) with 2 or more individual ECs (including at least one MIPS eligible clinician), as identified by their individual National Provider Identifier (NPI), who have reassigned their billing rights to the TIN.

For the second year of MIPS (2018), groups can register to utilize the CMS Web Interface and/or administer the CAHPS for MIPS survey between April 1, 2018 and June 30, 2018 (11:59pm EDT) via https://portal.cms.gov using a valid Enterprise Identity Management (EIDM) account.

This guide provides step-by-step instructions on how a group can register to participate in MIPS utilizing the CMS Web Interface and/or administer the CAHPS for MIPS survey for the 2018 performance year. This guide also includes instructions for modifying registration information and canceling registration for the CMS Web Interface and/or CAHPS for MIPS survey in the registration system.

Additional information about the Quality Payment Program, submission mechanisms and more can be found on the Quality Payment Program https://qpp.cms.gov/.

2. Getting Started

Create and Access your EIDM account. An individual from the group can sign-up for a new EIDM account or modify an existing account at https://portal.cms.gov. This step should be completed NOW to avoid any last minute delays in obtaining an EIDM account. An EIDM account must be obtained in advance in order for a

group’s registration to be submitted before the registration period closes on June 30, 2018 at 11:59pm EDT.

• To determine whether your group already has an individual who can register the group to utilize the CMS Web Interface and/or administer the CAHPS for MIPS survey, please contact the Quality Payment Program Service Center and provide the group's TIN and the name of the group.

Prepare to Register. Please gather the following information before you begin to register your group (as identified by its Medicare-billing TIN) in the registration system:

• Organization Information: Group Name, Entity Name, and Organization Mailing Address.

• Requestor Information: First Name, Last Name, Email, and Phone Number.

• Program Contact Information: First Name, Last Name, Email, Phone Number and Address.

• Technical Contact Information: First Name, Last Name, Email, Phone Number and Address.

• Determine your group size of clinicians: 2-24, 25-99, or 100 or more

• Determine your selection:

  • CMS Web Interface (for groups with 25 or more eligible clinicians)

Note: Some groups may have zero Medicare beneficiaries assigned for the CMS Web Interface as a result of patient attribution and sampling rules. If a group does not have any Medicare patients for any of the CMS Web Interface measures, the group will not meet the criteria for satisfactory reporting using the CMS Web Interface. CMS will notify groups that do not have any Medicare beneficiaries assigned, and such groups will need to participate in MIPS utilizing a different available submission mechanism.

• CAHPS for MIPS Survey (for groups with 2 or more eligible clinicians)

Note: In 2018, the CAHPS for MIPS survey is optional. For groups that have elected to administer the CAHPS for MIPS survey in 2018, you are responsible for selecting and paying a CMS-approved survey vendor to administer the surveys on your behalf. If it is determined that a group does not have a sufficient number of beneficiaries to produce valid and reliable CAHPS data, CMS will notify the group indicating that the group cannot participate in the administration of the CAHPS for MIPS survey and another data submission option is recommended. Groups should make sure to report on sufficient number of measures and activities via their other chosen submission mechanisms (Qualified Registry, QCDR, EHR, or CMS Web Interface) to meet program requirements.

Access the registration system. The registration system can be accessed at https://portal.cms.gov using a valid EIDM account. Information on obtaining an EIDM account to access the registration system is available at https://qpp.cms.gov/.

3. Steps to Submit a New 2018 Registration for the CMS Web Interface and/or CAHPS for MIPS Survey

   1. Go to https://portal.cms.gov. On the right hand side, select Log into CMS Secure Portal.

   2. After accepting the Terms and Conditions, enter your EIDM User ID on the Welcome to CMS Enterprise Portal screen and select Next.

   3. Enter the Password and the Multi-Factor Authentication (MFA) information and then select Log In to continue.

   4. Select the Quality Payment Program tab at the top of the screen, and then select CMS Web Interface / CAHPS for MIPS Survey from the dropdown menu. You will be directed to the Registration Welcome page.

   5. You will see a screen where the group(s) that are associated with your EIDM account are listed. To register a group for the 2018 CMS Web Interface and/or CAHPS, select the Register link under Action to the right of the group you want to register.

Note:

• If your group participates in an Accountable Care Organization (ACO) that is in the Medicare Shared Savings Program (Shared Savings Program) in 2018, then you will see an alert message letting you know that your TIN is participating in the Shared Savings Program in 2018. The Shared Savings Program is an Alternative Payment Model (APM) and your ACO should report quality data to CMS on your behalf. As a result, your registration in this registration system is unnecessary. If you have a question about this alert, please contact the Shared Savings Program at [email protected].

• You will see an alert message if there is at least one provider identified by a TIN/NPI combination billing under your TIN that participates in the Comprehensive Primary Care Plus, Next Generation ACO Model, or Comprehensive ESRD Care Model in 2018. You may continue to register the TIN for CMS Web Interface in the registration system. If you have a question about this alert, please contact the appropriate help desk:

  • Comprehensive Primary Care Plus: [email protected] or 1-888-372-3280

  • Next Generation ACO Model: [email protected]

  • Comprehensive ESRD Care Model: [email protected] or 1-888-734-6433

6. Enter the required information in the Organization Information and Requestor Information sections.

7. Select the appropriate Group Size, CMS Web Interface (as long as you have at least 25 clinicians), and CAHPS for MIPS Survey options. Select Save & Continue to save your information and proceed to the next screen.

8. Enter the required information in Program Contact Information and Technical Contact Information

sections. Select Save & Continue to save your information and proceed to the next screen.

Note: Select the check boxes if you want to pre-populate these sections with the information in the Requestor Information and your Organization’s mailing Address sections from the previous screen.

9. Verify that all of your information in the Summary screen is correct. To modify any of the information, select Edit. After you verify that the information is correct, select Submit to complete your registration and submit it to CMS.

Note: Your group will not be registered to utilize the CMS Web Interface and/or administer the CAHPS for MIPS survey for performance year 2018 until you select Submit. If you leave this screen without submitting your registration, then your registration will have “In-progress” status and not considered complete.

10. Record the Registration Identification Number provided in the Confirmation Message or select Print to print the Confirmation Message for your record. If you need to contact the Quality Payment Program Service Center to discuss your registration, please provide the Registration Identification Number. You will also receive an email with the Registration Identification Number confirming your registration.

4. Modify an Existing Registration for the

CMS Web Interface and/or CAHPS for MIPS Survey

You can modify an existing registration for the CMS Web Interface and/or CAHPS for MIPS survey for performance year 2018 (e.g., change your CMS Web Interface and/or CAHPS for MIPS survey selection) by logging into the registration system at any time before the registration period closes on June 30, 2018 at 11:59pm EDT and following the steps described below. If your group’s 2018 registration for the CMS Web Interface and/or CAHPS for MIPS survey was canceled by you or the Quality Payment Program Service Center and you want to re-register your group, then you must contact the Quality Payment Program Service Center at 1-866-288-8292 before the registration period closes.

1. See Steps 1-4 above

2. You will see a screen with a list of group(s) that are associated with your EIDM account. To modify an existing 2018 registration for the CMS Web Interface and/or CAHPS for MIPS survey, select the Modify link under Action to the right of the group whose registration you want to modify.

Note:

• If your group participates in an Accountable Care Organization (ACO) that is in the Medicare Shared Savings Program (Shared Savings Program) in 2018, then you will see an alert message letting you know that your TIN is participating in the Shared Savings Program in 2018. The Shared Savings Program is an Alternative Payment Model (APM) and your ACO should report quality data to CMS on your behalf. As a result, your registration in this registration system is unnecessary. If you have a question about this alert, please contact the Shared Savings Program at [email protected].

• You will see an alert message if there is at least one provider identified by a TIN/NPI combination billing under your TIN that participates in Comprehensive Primary Care Plus, the Next Generation ACO Model, or the Comprehensive ESRD Care Model in 2018. You may continue to register the TIN for CMS Web Interface in the registration system. If you have a question about this alert, please contact the appropriate help desk:

  • Comprehensive Primary Care Plus: or [email protected] or 1-888-372-3280

  • Next Generation ACO Model: [email protected]

  • Comprehensive ESRD Care Model: [email protected]or 1-888-734-6433

1. As needed, update the information in the Organization Information and Requestor Information sections. Update the Group Size, CMS Web Interface, and CAHPS for MIPS Survey options. Select Save & Continue to save your information and proceed to the next screen.

4. As needed, update the information in Program Contact Information and Technical Contact Information sections. Select Save & Continue to save your information and proceed to the next screen.

5. See Steps 9 and 10 above.

5. View your CMS Web Interface and/or

CAHPS for MIPS Survey Registration Summary

You can view a summary of your group’s 2018 registration information for or a previous year’s registration (if available).

1. Go to https://portal.cms.gov. On the right hand side, select Log into CMS Secure Portal.

2. After accepting the Terms and Conditions, enter your EIDM User ID on the Welcome to CMS Enterprise Portal screen and select Next.

3. Enter the Password and the Multi-Factor Authentication (MFA) information and then select Log In to continue.

4. Select the Quality Payment Program tab at the top of the screen, and then select CMS Web Interface / CAHPS for MIPS Survey from the dropdown menu. You will be directed to the Registration Welcome page.

5. You will see a screen with the list of group(s) that are associated with your EIDM account. Select the View

link under Action to the right of the group whose registration information you want to view.

6. You will see a Summary screen with the registration information provided.

Note:

• If you are viewing your group’s 2018 registration information and want to update any of the information, select Home to go back to the Welcome screen, and then select Modify. You will be able to modify a 2018 registration until the registration system closes on June 30, 2018 at 11:59pm EDT.

• If you are viewing a prior year’s registration information, then you will not be able to modify the registration.

6. Cancel Your 2018 Registration for the

CMS Web Interface and/or CAHPS for MIPS Survey

If your group registered to participate in MIPS utilizing the CMS Web Interface and/or administering the CAHPS for MIPS survey for the 2018 performance year, but wishes to cancel the registration, then you can log into the registration system and cancel the registration by following the steps described below OR contact the Quality Payment Program Service Center at 1-866-288-8292 before the registration period closes on June 30, 2018 at 11:59 pm EDT. You will not be allowed to cancel the group’s 2018 registration after this date. If you want to re-register the group to participate in MIPS utilizing the CMS Web Interface and/or administering the CAHPS for MIPS survey for the 2018 performance year, then you must contact the Quality Payment Program Service Center before the registration period closes.

1. See steps 1-4 in the Steps to Submit a New 2018 Registration for the CMS Web Interface and/or CAHPS for MIPS Survey section above.

2. You will see a screen where the group(s) that are associated with your EIDM account are listed. To cancel an existing 2018 registration for the CMS Web Interface and/or CAHPS for MIPS survey, select the Cancel link under Action to the right of the group whose registration you want to cancel.

3. Respond to the following Cancel Alert message: “Are you sure you want to cancel your TIN’s registration for participation in MIPS utilizing the CMS Web Interface and/or administering the CAHPS for MIPS survey for performance year 2018? If you would like to re-register your TIN after cancelation, you will need to contact the Quality Payment Program Service Center at 1-866-288-8292 for assistance.”

   • Yes (Cancel)

   • No (Do Not Cancel)

4. A cancelation pop-up box will be displayed when you select Yes (Cancel). Enter the reason for canceling the registration (maximum of 1500 characters allowed).

5. Select Submit to cancel your group’s registration to participate in MIPS utilizing the CMS Web Interface and/or administering the CAHPS for MIPS survey for performance year 2018.

6. Record the Registration Identification Number provided in the Confirmation Message or select Print to print the Confirmation Message for your record. If you need to contact the Quality Payment Program Service Center to discuss your registration, please provide the Registration Identification Number. You will also receive an email with the Registration Identification Number confirming your registration cancelation.

Note:

• If you did not intend to cancel the group’s registration, please contact the Quality Payment Program at 1-866-288-8292 as soon as possible to re-register your group before the registration period closes on June 30, 2018 at 11:59pm EDT.

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 0938-1314. The time required to complete this information collection is estimated to average 1 hour 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.

OMB No. 0938-1314

Expiration Date: XX/XX/XXXX

If you have questions or need further assistance regarding an EIDM account, please contact the Quality Payment Program by phone at 866-288-8292 (TTY 1-877-715-6222) or by e-mail at [email protected]. Business hours are Monday-Friday from 8:00am to 8:00pm ET.

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