CMS-10394 QECP Data Source Attestation

Revised 12/8/2017

QECP Data Sourc Att station Workbook
Instructions
The purpose of this work ook is to provide entities with an easy-to-use template for su mitting all information regarding other-payer sources of claims data and
the total num er of covered lives in a QE's geographic area. Completion of this work ook egins to satisfy the Element 2A requirements of the QECP Phase 1
minimum requirements review.
This instructions page is divided into three sections:

Instructions for Completing the Data Source Attestation worksheet (starts on row 11)

Instructions for Completing the Covered Lives Calculator worksheet (starts on row 33)

Instructions for Completing the Covered Lives y State worksheet (starts on row 47)

Instructions for Compl ting th "Data Sourc Att station" Worksh

t

1.

Provide Entity information (Rows 8-12).

2.

Complete the Provider Reporting Profile (Row 17).

Provide the proportion of practicing providers in the geographic area that will e included in the entity's performance reports.

3.

Enter the num er of Claims Data Suppliers (Cell B20).

Provide the num er of claims data suppliers relevant to the QE application.

Please copy and paste Rows 24 through 70 for each additional data supplier your organization possesses.

4.

Complete a Data Supplier Profile ta le for ach
claims data supplier relevant to the QE application ( eginning on Row 25).

Complete the general contact information related to each relevant claims data supplier.

Provide the volume of other-payer claims data, including covered lives.

Provide the geographic coverage area of data (i.e., state, county) received from the claims data supplier to e included in QE performance reports.

Select all provider types included in the data received from the claims data supplier.

Select if clinical or pharmacy claims data will also e provided y the claims data supplier. If yes, descri e the volume of the data and select
whether it will e incorporated into the claims- ased QE measures.

Select if individual providers are identified in the data received from the claims data supplier.

Select if the other-payer claims data received from the data supplier is pre-adjudicated and whether measures related to costs will e produced using
data from this supplier.

5.

Complete the Signature section.

Instructions for Compl ting th "Cov r d Liv s Calculator" Worksh

t

1.

Select the states and/or counties for which your organization is reporting (or plans to report).

Hold CTRL to select multiple states or counties.

To select a whole state, please select the state and then *TOTAL - State, which should e the first option in the county ox.

2.

In the lue ox, enter the total num er of other-payer covered lives included in the data sources o tained (not including QE Medicare data).

3.

Explain in the "Additional Comments" (Column I) if your organization plans to report on a region smaller than a county.

Pl as not that th sourc s of data from this worksh t includ :
Yearly Enrollment Counts, 2016 Original Medicare. Updated 11/28/2017. "Medicare FFS Covered Lives." (Populates column E under Step 3)
Medica e En ollment Dashboa d Data File
Ame ican FactFinde

QECP Data Source Attestation.xlsx

Ta le S2701 - Health Insurance Coverage Status, 2016 ACS 5-year estimates, Num er Insured. Accessed 12/7/2017. "Total CL in Geographic Region."
(Populates column C under Step 3)

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Instructions

Instructions for Compl ting th "Cov r d Liv s by Stat " Worksh

t

1.

Only complete the Covered Lives y State worksheet if your organization is planning to report at the national level.

2.

Enter the total num er of covered lives your organization possesses in the United States.

3.

Enter the num er of covered lives your organization possesses y state.

4.

Please note that only column C should e completed. All other cells will auto-populate ased on the information provided.

CMS#10394 (0938-1144) Exp. XX/XX/XXXX
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 num er. The valid
OMB control num er 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.

QECP Data Source Attestation.xlsx

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Instructions

Revised 10/16/2017

QECP Data Source Attestation
Lead Entity Applying for the Qualified Entity Certification Program (QECP)
Legal ame of Applying Entity
Trade ame/DBA
ame of Data Recipient
(if diffe ent f om Applying Entity)

Comple e he Provider Repor ing Profile able once.
Provider Reporting Profile
1. For he provider ypes (specified in Elemen 1D)
in he geographic region (specified in Elemen 1C) you
in end o repor , wha propor ion of hese prac icing
providers will be included in your performance
repor s?

umber of Other-Payer Claims Data Suppliers
umber of Other-Payer Claims Data Suppliers
Relevant to the QE application:

Comple e a Da a Supplier Profile able for each claims data supplier

relevan o he en i y’s QE applica ion and program.

Please copy and paste Rows 24 through 70 for each additional data supplier your organization
possesses.

Claims Data Supplier Profile:
Legal ame of Claims Data Supplier
Trade ame/DBA
Effective Dates of Agreement
Contact ame
Contact Title
Contact Email
Street Mailing Address
Suite/Mail Stop
City, State, Zip
Phone
Fax
Website URL
Data Detail
1. Volume of Other-Payer Data

Covered Lives:
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:
For partial covered states, list
Counties covered:

2. Geographic Coverage Area of Data Received from OR

QECP Da a Source A es a ion.xlsx

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Da a Source A es a ion

Supplier to be Included in QE Performance Reports
MSAs covered:
OR

Other regional boundary:
Individu l Clinici n (physici ns, nurses, etc.)
Clinic
Group/ Pr ctice

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

Te m
F cility
He lth Pl n Defined Group of Physici ns
Integr ted Delivery System
Other

Specify:
4. The information provided describes the
claims data received from this supplier.
Please also respond to the following:
If yes, describe
volume:

Yes

4a. Do you also receive clinical data (e.g., registry
data, electronic health records) from this supplier?

No

Yes

No

If yes, describe
volume:

Yes

4b. Do you also receive pharmacy claims data from
this supplier?

If yes, do you intend to incorporate this into your
claims-based QE measures?

If yes, do you intend to incorporate this into your
claims-based QE measures?

Yes

No
No

Per 42 CFR §401.703 (h), "Claims data from other sources means provider- or
supplier-identifiable claims data that an applicant or qualified entity has full data
usage right to due to its own operations or disclosures from providers, suppliers,
private payers, multi-payer databases, or other sources."

Yes

5. Are individual providers identified in the claims data
received from this supplier?

No

ote: Claims data sources that do not identify individual providers cannot be used
to satisfy Element 2A.
6. Are the claims data received from this supplier preadjudicated?

Does your organization plan to produce
measures related to cost using data from this
supplier?

Yes
No

Yes
No

<- Please right click and click "Insert copied cells." Paste as many
additional data supplier profiles as needed starting here.

Signature
To he bes of my knowledge and belief, all da a in his a es a ion are rue and correc . The documen has been au horized by he Qualified En i y Cer ifica ion Program (QECP) En i y
in reference o he QECP En i y’s da a supplier(s).
Au horized Represen a ive Name (prin ed):
Au horized Represen a ive Ti le (prin ed):

QECP Da a Source A es a ion.xlsx

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Da a Source A es a ion

Signa ure:
Da e:
Phone:

QECP Da a Source A es a ion.xlsx

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Da a Source A es a ion

Revis ed 12/8/2017

This works heet walks entities through a s imple and automated three-s tep proces s for reporting the percentage of covered lives in an entity's anticipated public performance reports bas ed on the entity's geographic reporting area. Step
1 requires the entity to s elect the s tates and/ or counties for which the entity plans to report. Step 2 requires the entity to enter the total number of other-payer covered lives included in the claims data s ources the entity has obtained.
Step 3 requires the entities that are planning to report on a region s maller than a county to provide an explanation in the "Additional omments " column.
Step 1: Select the s tates and/ or counties for which your organiz ation plans to report.
C unty

States
H old CTRL to s elect multiple s tates or counties .

York-Penns ylvania

To s elect a whole s tate, s elect the s tate and then *TO TAL - State, which s hould be the firs t option in the county box.

Alabama
York-South Carolina
Alas ka

York-Virginia

Ariz ona

Young- exas
Yuba-California

Arkans as

Yukon-Koyukuk-Alas ka
Yuma-Ariz ona

California

Yuma-Colorado
Colorado
Zapata- exas
Connecticut

Zavala- exas

Delaware

Ziebach-South Dakota

Dis trict of Columbia
Florida
G eorgia

Total overed Lives from O ther-Payer
Sources of laims Data:
Step 2: Enter the total number of other-payer covered lives included in the claims data s ources you have obtained in the blue box (not including QE Medicare data):

Step 3: If your organiz ation plans to report on a region s maller than a county, pleas e explain in the "Additional omments " ( olumn I). For example, if your organiz ation plans to report on the wes tern half of Bullock ounty, Alabama,
pleas e s elect Bullock ounty in Step 1 (above) and explain in olumn J in the corres ponding row in Step 3 (below) that your organiz ation will only report on the wes tern half of Bullock ounty.

C vered L ives
T tal CL in
States

C unty

C vered L ives f r

G e graphic

Other-Payer

Regi n

S urces f D ata

M edicare FFS

(Other +

% C vered L ives

% C vered L ives

C vered L ives

M edicare

Exc luding FFS data

Including FFS data

Additi nal C mments
FFS)

Alabama

* O AL - Alabama-Alabama

Alas ka

* O AL - Alas ka-Alas ka

Ariz ona

* O AL - Ariz ona-Ariz ona

4,208,373

725,205

592,366

87,462

5,718,154

727,864

Arkans as

* O AL - Arkans as -Arkans as

2,555,830

477,553

California

* O AL - California-California

33,347,804

3,354,480

Colorado

* O AL - Colorado-Colorado

4,695,668

515,093

Connecticut

* O AL - Connecticut-Connecticut

3,282,924

471,782

Delaware

* O AL - Delaware-Delaware

851,491

169,044

Dis trict of Columbia

* O AL - Dis trict of Columbia-Dis trict o

614,844

77,310

Florida

* O AL - Florida-Florida

16,409,867

2,457,552
1,045,115

G eorgia

* O AL - G eorgia-G eorgia

8,341,825

H awaii

* O AL - H awaii-H awaii

1,291,876

137,456

Idaho

* O AL - Idaho-Idaho

1,396,620

199,345
1,616,176

Illinois

* O AL - Illinois -Illinois

11,438,252

Indiana

* O AL - Indiana-Indiana

5,742,314

884,882

Iowa

* O AL - Iowa-Iowa

2,868,244

481,973
425,059

Kans as

* O AL - Kans as -Kans as

2,541,808

Kentucky

* O AL - Kentucky-Kentucky

3,911,579

637,283

Louis iana

* O AL - Louis iana-Louis iana

3,901,152

557,828

Maine

* O AL - Maine-Maine

1,190,880

235,241

Maryland

* O AL - Maryland-Maryland

5,389,007

865,020

Mas s achus etts

* O AL - Mas s achus etts -Mas s achus

6,451,367

978,317

Michigan

* O AL - Michigan-Michigan

8,974,782

1,249,002

Minnes ota

* O AL - Minnes ota-Minnes ota

5,064,015

418,200

Mis s is s ippi

* O AL - Mis s is s ippi-Mis s is s ippi

2,496,059

478,920

Mis s ouri

* O AL - Mis s ouri-Mis s ouri

5,272,765

810,311

Montana

* O AL - Montana-Montana

869,709

166,971

N ebras ka

* O AL - N ebras ka-N ebras ka

1,673,395

280,703

N evada

* O AL - N evada-N evada

2,350,721

311,020

N ew H amps hire

* O AL - N ew H amps hire-N ew H am

1,200,297

250,822

N ew Jers ey

* O AL - N ew Jers ey-N ew Jers ey

7,868,933

1,267,546

N ew Mexico

* O AL - N ew Mexico-N ew Mexico

N ew York

* O AL - N ew York-N ew York

1,753,906

260,998

17,785,491

2,129,183

8,455,476

1,258,606

10,443,792

1,367,971

N orth Carolina

* O AL - N orth Carolina-N orth Carolin

Ohio

* O AL - Ohio-Ohio

Oklahoma

* O AL - Oklahoma-Oklahoma

3,200,667

571,301

Oregon

* O AL - Oregon-Oregon

3,532,593

436,383

11,579,382

1,545,641

955,002

132,565

Penns ylvania

* O AL - Penns ylvania-Penns ylvania

Rhode Is land

* O AL - Rhode Is land-Rhode Is land

South Carolina

* O AL - South Carolina-South Carolin

South Dakota

* O AL - South Dakota-South Dakota

ennes s ee

* O AL - ennes s ee- ennes s ee

exas

* O AL - exas - exas

U tah

QECP Data Source Attes tation.xls x

* O AL - U tah-U tah

4,108,301

734,558

747,562

126,316

5,687,677

814,032

21,364,057

2,488,770

2,572,238

234,687

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Covered Lives Calculator

Vermont

* O AL - Vermont-Vermont

587,407

124,745

Virginia

* O AL - Virginia-Virginia

7,232,481

1,118,937

W as hington

* O AL - W as hington-W as hington

6,282,974

863,098

W es t Virginia

* O AL - W es t Virginia-W es t Virginia

1,642,376

306,401

W is cons in

* O AL - W is cons in-W is cons in

5,273,102

T tals :

QECP Data Source Attes tation.xls x

275,717,405

660,229
-

37,534,956

37,534,956

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0.00%

13.61%

Covered Lives Calculator

Revised 12/8/17

Covered Lives by State
Please note that this worksheet must be completed if the entity plans to report at the national level (all 50 states and DC).
You may disregard this worksheet if your organization does not plan to report at the national level.
This w rksheet walks entities thr ugh a simple and aut mated tw -step pr cess f r rep rting the number f c vered lives that
an entity p ssesses by state. Step 1 requires the entity t enter the t tal number f ther-payer c vered lives it p ssesses in the
United States in cell C5 (this is the same number rep rted in cell I14 in the "C vered Lives Calculat r" w rksheet). Step 2
requires the entity t enter the number f ther-payer c vered lives it p ssesses by state in cells C6-C56.

Geogra hic
Region
USA
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
DC
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
1
2

Covered Lives from
Covered Lives
Total CL in
Medicare FFS
1 Other-Payer Sources
2 (Other + Medicare
Geogra hic Region
Covered Lives
of Data
FFS)
276,875,891
4 208 373
592 366
5 718 154
2 555 830
33 347 804
4 695 668
3 282 924
851 491
614 844
16 409 867
8 341 825
1 291 876
1 396 620
11 438 252
5 742 314
2 868 244
2 541 808
3 911 579
3 901 152
1 190 880
5 389 007
6 451 367
8 974 782
5 064 015
2 496 059
5 272 765
869 709
1 673 395
2 350 721
1 200 297
7 868 933
1 753 906
17 785 491
8 455 476
658 279
10 443 792
3 200 667
3 532 593
11 579 382
955 002
4 108 301
747 562
5 687 677
21 364 057
2 572 238
587 407
7 232 481
6 282 974
1 642 376
5 273 102
500 207

% Covered % Covered
Lives
Lives
Excluding Including FFS
FFS data
data

37,727,575
725 205
87 462
727 864
477 553
3 354 480
515 093
471 782
169 044
77 310
2 457 552
1 045 115
137 456
199 345
1 616 176
884 882
481 973
425 059
637 283
557 828
235 241
865 020
978 317
1 249 002
418 200
478 920
810 311
166 971
280 703
311 020
250 822
1 267 546
260 998
2 129 183
1 258 606
97 913
1 367 971
571 301
436 383
1 545 641
132 565
734 558
126 316
814 032
2 488 770
234 687
124 745
1 118 937
863 098
306 401
660 229
94 706

Source: American Factfinder - Table S2701 - Health Insurance Coverage Status 2016 ACS 5-year estimates Number Insured. Accessed 12/7/2017.
Source: Medicare Enrollment Dashboard Data File - Yearly Enrollment Counts 2016 Original Medicare. Updated 11/28/2017.

QECP Data Source Attestation.xlsx

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Covered Lives by State