Form CMS-10673 Qualifying Payment Arrangement Form

OMB Control Number: 0938-XXXX
Expires: XX/XX/XXXX

Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration
Submission Form for Medicare Advantage Qualifying Payment Arrangement Incentive
(MAQI) Demonstration Qualifying Payment Arrangements (Qualifying Payment
Arrangement Submission Form)

Purpose
The Qualifying Payment Arrangement Submission Form (Form) may be used by MAQI
participants that participate in payment arrangements with Medicare Advantage Health Plans to
request that CMS determine whether a payment arrangement is a Qualifying Payment
Arrangement under the MAQI Demonstration, authorized under Section 402 of the Social
Security Amendments. This process is called the MAQI Qualifying Payment Arrangement
Determination Process (Qualifying Payment Arrangement Process). The Qualifying Payment
Arrangement Process may be used for payment arrangements under Medicare Advantage Health
Plans.
The Qualifying Payment Arrangement Process occurs following the relevant MAQI
Demonstration Performance Period.
A federally mandated independent evaluation will be conducted of the MAQI demonstration.
Evaluation activities are aimed at understanding the effects of the MAQI Demonstration. You
may be contacted to provide additional information.

Deadlines
For 2018, the submission period for the Qualifying Payment Arrangement Process is projected to
be from October 24 through November 21, 2018. CMS is projecting 30 days for the submission
period. CMS intends to review and provide determinations for submitted Forms in December
2018.
Different payment arrangements must be submitted separately. You must submit the required
information pertaining to each payment arrangement you wish to have reviewed.
Additional Information
CMS will review the payment arrangement information in this Form to determine whether the
payment arrangement meets the Qualifying Payment Arrangement criteria under the MAQI
Demonstration. If you submit incomplete information and/or more information is required to
make a determination, CMS will notify you and request the additional information that is needed.

You must return the requested information no later than 3 business days from the notification
date. If you do not submit sufficient information within this time period, CMS will not make a
determination regarding the payment arrangement. As a result, the payment arrangement would
not be considered a Qualifying Payment Arrangement for the year. These determinations are
final and not subject to reconsideration.
Notification
CMS intends to notify MAQI participants of determination decisions in December 2018 for
Forms submitted during the October/November 2018 submission period.
Instructions for Completing and Submitting this Form
All Forms must be completed and submitted electronically through the CMS website.
In addition to MAQI participants, we allow those authorized to report on behalf of MAQI
participants to complete this Form.
This Form contains the following sections:
Section 1: MAQI Participant
Section 2: Payment Arrangement Information
Section 3: Supporting Documentation
Section 4: Certification Statement
MAQI participants must complete all four sections.
All required supporting documentation must be uploaded as attachments in the Supporting
Documentation section of the Form.

SECTION 1: MAQI Participant Identifying Information
A. MAQI Participant Information
1. Complete this section for each MAQI participant for whom you are reporting.
2. Applicant Legal Name: ____________
3. List the first name(s), last name(s), and NPI(s) of each MAQI participant participating in
the payment arrangement. [TEXT BOX FOR EACH NPI]
4. Taxpayer Identification Number (TIN): _______________
5. DBA Name (if applicable): _________________

6. Parent Company or Organization (if applicable): ________________
7. Contact Information:
Telephone Number: ____ Fax Number: ____________
Address Line 1 (Street Name and Number): _________
Address Line 2 (Suite, Room, etc.): ___________
City/Town: ______ State: _____ Zip Code +4: ____________
E-mail Address: _______________

SECTION 2: Payment Arrangement Information
A.

General Information
1. Payment Arrangement Name (e.g. [Payer Name] Oncology Care Model), or terminology

used to refer to the payment arrangement: [TEXT BOX]
2. State the health insurance company and plan name under which this payment
arrangement was implemented. [TEXT BOX]
3. Payer Contact Person for this payment arrangement:
Name: ______________
Title: _______________
Telephone Number: _______________
E-mail Address: __________________
4. Describe the participant eligibility criteria for this payment arrangement. [TEXT BOX]
5. Is this payment arrangement open to all provider types or limited to certain specialties?
[SELECT ONE]
If the payment arrangement is limited to certain specialties, select the provider
specialties that may participate in the payment arrangement. [DROP-DOWN]

B. Payment Arrangement Documentation
Please attach documentation that supports responses to the questions asked in Section C
(Information for Qualifying Payment Arrangement Determination) of this Form. Supporting
documents may include contracts or excerpts of contracts between you and the payer, or
alternative comparable documentation that supports responses to the questions asked in Section
C below.

Upload all documents to the Supporting Documentation section of this Form, and label each
document for reference throughout the Form.

C. Information for Qualifying Payment Arrangement Determination
Certified Electronic Health Record Technology (CEHRT)
1. List the attached document(s) and page numbers that contain the information required in
this section. [TEXT BOX]
2. Does the payment arrangement require at least 50 percent of clinicians participating in
the payment arrangement to use CEHRT as defined in 42 CFR 414.1305 to document and
communicate clinical care? [Y/N]
Quality Measure Use
1. List the attached document(s) and page numbers that contain the information required in
this section. [TEXT BOX]
2. Does the payment arrangement apply any quality measures that are comparable to MIPS
quality measures as described by 42 CFR 414.1420(c)? [Y/N]
3. If yes, does at least one quality measure have an evidence-based focus, is it reliable and
valid, and does it meet at least one of the following criteria: [Y/N]
-

Any of the quality measures included on the proposed annual list of MIPS quality
measures;
Quality measures that are endorsed by a consensus-based entity;
Quality measures developed under section 1848(s) of the Act;
Quality measures submitted in response to the MIPS Call for Quality Measures
under section 1848(q)(2)(D)(ii) of the Act or
Any other quality measures that CMS determines to have an evidence-based focus
and are reliable and valid.

4. A minimum of one quality measure that meets the above criteria and is an outcome
measure is required in order to satisfy the Quality Measure Use criterion. Please provide
the following information for each quality measure included in the payment arrangement
that you wish for CMS to consider for purposes of satisfying this criterion. [TEXT BOX
FOR EACH MEASURE]
-

Measure title
MIPS measure identification number (if applicable)
National Quality Forum (NQF) number (if applicable)

-

-

If the measure is neither a MIPS measure nor a currently endorsed NQF measure,
cite the scientific evidence and/or clinical practice guidelines that support the use
of the measure.
Is the measure an outcome measure?
Describe how the measure has an evidence-based focus, is reliable and valid, by
meeting one the following criteria:

o Any of the quality measures included on the proposed annual list of MIPS
quality measures;
o Quality measures that are endorsed by a consensus-based entity;
o Quality measures developed under section 1848(s) of the Act;
o Quality measures submitted in response to the MIPS Call for Quality
Measures under section 1848(q)(2)(D)(ii) of the Act or
o Any other quality measures that CMS determines to have an evidencebased focus and are reliable and valid
5. Are any of the above measures outcome measures? [Y/N]
If no, check here if no outcomes measures that are relevant to this payment arrangement are
available on the MIPS quality measure list. [CHECK BOX]
Past Payment Arrangements (for informational purposes only)
In 2017, did you participate in any Medicare Advantage plan with requirements similar to those
described above? [Y/N] (This information will not be used to determine eligibility for the MAQI
demonstration.)

Generally Applicable Financial Risk Standard
1. List the attached document(s) and page numbers that contain the information required in
this section. [TEXT BOX]
2. Does the payment arrangement require you to bear financial risk if actual aggregate
expenditures exceed expected aggregate expenditures (i.e. benchmark amount)? [Y/N]
3. If yes, which of the following actions does the payer take in cases where actual aggregate
expenditures exceed expected aggregate expenditures? [CHECK BOX]
- Payer withholds payment of services to the participants in the Qualifying Payment
Arrangement.
- Payer reduces payment rates to participants in the Qualifying Payment Arrangement.
- Payer requires direct payments by the participants in the Qualifying Payment
Arrangement to the payer.

Please describe the action(s) checked above that are taken by the payer in cases where
actual aggregate expenditures exceed expected aggregate expenditures. [TEXT BOX]
4. Is this payment arrangement a capitation arrangement? [Y/N]
A capitation arrangement for purposes of Qualifying Payment Arrangement
determinations is a payment arrangement in which a per capita or otherwise
predetermined payment is made under the payment arrangement for all items and
services for which payment is made through the payment arrangement furnished to a
population of beneficiaries, and no settlement is performed for reconciling or sharing
losses incurred or savings earned.
If yes, describe how this payment arrangement is a capitation arrangement. [TEXT BOX]

Generally Applicable Nominal Amount Standard
1. List the attached document(s) and page numbers that contain the information required in
this section. [TEXT BOX]
2. Please briefly describe the payment arrangement’s risk methodology. Note the risk
rate(s), expenditures that are included in risk calculations, circumstances under which
you are required to repay or forego payment, and any other key components of the risk
methodology. [TEXT BOX]
3. Is the marginal risk that you potentially owe or forego under the payment arrangement at
least 30 percent? [Y/N]
If yes, please describe the marginal risk rate(s) and the actions required (e.g., repayment
or forfeit of future payment) under the payment arrangement. [TEXT BOX]
4. Is the minimum loss rate with which you operate under the payment arrangement no
more than 4 percent? [Y/N]
If yes, please describe the minimum loss rate. [TEXT BOX]
5. Is the total amount that you owe or forgo under the payment arrangement at least:
- 8 percent of the total revenue from the payer of your providers and suppliers in the
payment arrangement if financial risk is expressly defined in terms of revenue [Y/N]
If yes, please explain how risk is expressly defined in terms of revenue. [TEXT BOX]
-

3 percent of the expected expenditures for which you are responsible under the
payment arrangement? [CHECK BOX]
If yes, please describe the amount that you owe or forego is calculated. [TEXT BOX]

SECTION 3: Supporting Documentation
Please upload all supporting documentation here. Documents should be labeled for reference
use throughout the Form.

SECTION 4: Certification Statement
MAQI Participant
I have read the contents of this submission. By submitting this Form, I certify that the
information contained herein is true, accurate, and complete, and I authorize the Centers for
Medicare & Medicaid Services (CMS) to verify this information. If I become aware that any
information in this Form is not true, accurate, or complete, I will notify CMS of this fact
immediately. I understand that the knowing omission, misrepresentation, or falsification of any
information contained in this document or in any communication supplying information to CMS
may be punished by criminal, civil, or administrative penalties, including fines, civil damages
and/or imprisonment.
[DATE, MAQI participant]

Third Party Submitting on Behalf of MAQI Participant
I have read the contents of this submission. By submitting this Form, I certify that I am legally
authorized to submit this Form on behalf of each MAQI participant specified in the MAQI
Participant Identifying Information section of this Form. I further certify that the information
contained herein is true, accurate, and complete, and I authorize the Centers for Medicare &
Medicaid Services (CMS) to verify this information. If I become aware that any information in
this Form is not true, accurate, or complete, I will notify CMS of this fact immediately. I
understand that the knowing omission, misrepresentation, or falsification of any information
contained in this document or in any communication supplying information to CMS may be
punished by criminal, civil, or administrative penalties, including fines, civil damages and/or
imprisonment.
[DATE, AUTHORIZED INDIVIDUAL NAME, TITLE, NAME OF THIRD PARTY ENTITY
(if applicable)]
For a third party submitting on behalf of a MAQI participant, that third party must also submit as
supporting documentation the following certification from each MAQI participant that the third
party is reporting on behalf of:
I have read the contents of this submission. I am authorized to submit this Form on behalf of the
MAQI Participant. . I certify that the information contained herein is true, accurate, and
complete, and I authorize the Centers for Medicare & Medicaid Services (CMS) to verify this
information. If I become aware that any information in this Form is not true, accurate, or
complete, I will notify CMS of this fact immediately. I understand that the knowing omission,
misrepresentation, or falsification of any information contained in this document or in any

communication supplying information to CMS may be punished by criminal, civil, or
administrative penalties, including fines, civil damages and/or imprisonment.
[DATE, MAQI participant]

Qualifying Payment Arrangement Submission Form Privacy Act Statement
The Centers for Medicare & Medicaid Services (CMS) is authorized to collect the information
requested on this Form by Section 402 of the Social Security Amendments of 1967 (as
amended).
The purpose of collecting this information is to determine whether the submitted payment
arrangement is a Qualifying Payment Arrangement as defined in the MAQI Demonstration for
the relevant Performance Period.
The information in this request will be disclosed according to the routine uses described below.
Information from these systems may be disclosed under specific circumstances to:
1. CMS contractors to carry out Medicare functions, collating or analyzing data, or to detect
fraud and abuse;
2. A congressional office in response to a subpoena;
3. To the Department of Justice or an adjudicative body when the agency, an agency
employee, or the United States Government is party to litigation and the use of the
information is compatible with the purpose for which the agency collected the
information;
4. To the Department of Justice for investigating and prosecuting violations of the Social
Security Act, to which criminal penalties are attached.
Protection of Proprietary Information
Privileged or confidential commercial or financial information collected in this Form is protected
from public disclosure by Federal law 5 U.S.C. 552(b)(4) and Executive Order 12600.
Protection of Confidential Commercial and/or Sensitive Personal Information
If any information within this request (or attachments thereto) constitutes a trade secret or
privileged or confidential information (as such terms are interpreted under the Freedom of
Information Act and applicable case law), or is of a highly sensitive personal nature such that
disclosure would constitute a clearly unwarranted invasion of the personal privacy of one or
more persons, then such information will be protected from release by CMS under 5 U.S.C.
552(b)(4) and/or (b)(6), respectively.

PRA Disclosure Statement
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OMB control number. The valid OMB control number for this information collection is 0938-XXXX (Expires XX/XX/XXXX). The time
required to complete this information collection is estimated to average 10 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
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this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents,
please contact John Amoh at [email protected].