CMS-10673 Threshold Data Submission Form

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

Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration
Submission Form for Requests for MIPS Exclusion Determinations under the MAQI
Demonstration
(Threshold Data Submission Form)

Welcome to the Threshold Data Submission Form
Purpose
The Threshold Data Submission Form (Form) may be used to request that CMS determine
whether participants in the MAQI Demonstration are to receive waivers from Merit-based
Incentive Payment System (MIPS) reporting and payment consequences. This process is called
the MIPS waiver determination process.
The MAQI Demonstration will allow participating clinicians to have the opportunity to be
eligible for waivers that will exempt them from the MIPS reporting requirements and payment
adjustment for a given year if they participate to a sufficient degree in Qualifying Payment
Arrangements with MAOs (combined with participation in Advanced APMs with Medicare FFS,
if any) during the performance period for that year, without requiring them to be QPs or Partial
QPs, or to otherwise meet MIPS exclusion criteria.
Demonstration participants who meet either the payment amount threshold or the patient count
threshold shown below for at least one of three snapshots (January 1 – March 31, January 1 –
June 30, or January 1 – August 31) during the performance period for a given year of the Quality
Payment Program (QPP) will receive waivers from MIPS reporting and payment consequences
for that year of QPP.
Performance Period Year
Payment Amount Threshold1 Patient Count Threshold2
2018
25%
20%
2019
50%
35%
2020
50%
35%
2021
75%
50%
2022
75%
50%
Notes: 1 Equals percent of total Medicare FFS and MA payments that are under the terms of
Advanced APMs/Qualifying Payment Arrangements.
2
Equals percent of total Medicare FFS and MA patients that are under the terms of Advanced
APMs/Qualifying Payment Arrangements.

This Form collects Medicare Advantage payment and patient count information, for purposes of
calculating payment amount and patient count threshold scores. Because CMS has access to
Medicare FFS payment amount and patient count information internally, MAQI participants do
not need to submit Medicare FFS data in this Form.
MAQI participants requesting MIPS exclusion determinations must submit this Form no later
than October 31 of the year of the Performance Period (except in the first performance year
where CMS anticipates this date to be in November 2018). CMS will not review Forms
submitted after the Submission Deadline.

Additional Information
CMS will review the Qualifying Payment Arrangement participation information in this Form to
determine whether the MAQI participant meets the conditions to receive waivers from MIPS
reporting and payment consequences. If incomplete information is submitted and/or more
information is required to make a determination, CMS will notify the MAQI participant and
request the additional information that is needed. MAQI participants must return the requested
information no later than 3 business days from the notification date. If the MAQI participant
does not submit sufficient information within this time period, the MAQI participant will not be
excluded from MIPS for that year. These determinations are final and not subject to
reconsideration.
Notification
CMS will notify MAQI participants of whether they met the MIPS exclusion criteria as soon as
possible after determinations are made.
MAQI participants may submit information on any or all of the three snapshot periods: January 1
through March 31, January 1 through June 30, or January 1 through August 31. Complete
information for all MA plans must be included for whichever snapshot period(s) the MAQI
participant chooses to submit.
The MAQI participant or an authorized agent of the MAQI participant may submit the Form on
behalf of the MAQI participant. In submitting the Form, the submitter attests that he or she is
qualified to make the assertions contained herein as the MAQI participant or an agent of the
MAQI participant and that the assertions contained herein are true and accurate with respect to
this Form.
All Forms must be completed and submitted electronically.
This Form contains the following sections:
Section 1: MAQI Participant Identifying Information
Section 2: Qualifying Payment Arrangement Participation Data
Section 3: Certification Statement

MAQI participants must complete Sections 1 and 3 in their entirety. Section 2 include options for
submitting data for any of the three snapshot periods. MAQI participants may submit
information for any or all of the three snapshot periods. It is strongly recommended, though not
required, that MAQI participants submit both patient count and payment amount information for
whichever snapshot period(s) they choose.

SECTION 1: MAQI Participant Identifying Information
A.

Point of Contact for this Form
1. Name:________________________
2. Job Title:_________________________
3. Organization Name:______________________
4. Email:__________________________
5. Confirm Email:__________________________
6. Phone Number:__________________________ Ext:____________________
7. Address Line 1 (Street Name and Number): ___________________________
Address Line 2 (Suite, Room, etc.): _________________________
City: ________________ State: _____ Zip Code +4: ____________

B.

MAQI Participant Information
1. Name of MAQI participant: ________________________
2. MAQI participant’s NPI:__________________________
3. Advanced APM(s) in which MAQI participant participates [DROP DOWN LIST,
allow multiple selections]
3a. [For each Advanced APM selected] Model participation
ID:______________
[Help bubble text: This refers to the unique identifier that the Advanced APM
has assigned to the APM Entity through which the MAQI participant
participates. It is most often a short combination of letters and numbers (for
example, V### or E####). If you are unsure of your Model participation ID,
please reach out to the point of contact for your Advanced APM.]
3b. [For each Advanced APM selected] TIN through which MAQI participant
participates in the Advanced APM:_________________
3c. [For each Advanced APM selected] Name of the point of contact for the
APM Entity at CMS (optional):____________________

SECTION 2: Qualifying Payment Arrangement Participation Data
Information for all MA plans through which the MAQI participant furnished services must be
included. MAQI participants may choose to submit information for any or all of the snapshot
periods; you are not required to submit information for all three snapshot periods. In order to
have a MIPS exclusion determination made for a snapshot period, you must enter information
for every MA plan for that snapshot period.
Please note that CMS may validate your Qualifying Payment Arrangement participation
information with the MA plans you include in this Form.
Add a Plan + [Button] [Users will enter the below information for each plan, and there is no
limit on the number of plans for which they may enter information. After the information below
has been entered for each plan, display a chart summarizing the plans entered so far, and allow
users to press this button again to add another payer]

A. Plan Name:___________________________
B. Did the MAQI participant participate in a Qualifying Payment Arrangement with this
plan during the Performance Period (January 1 – August 31)? [Y/N]
B1. [If yes] Name(s) of Qualifying Payment Arrangement(s): Note: the name listed here must
match the name that the MAQI participant used when submitting the Qualifying Payment
Arrangement determination request to CMS. You may select more than one Qualifying
Payment Arrangement per plan. [free text]:_______________________
B2. [If yes, for each Qualifying Payment Arrangement] Contract # (if applicable):_________
[Help bubble text: This refers to the unique identifier that the Qualifying Payment
Arrangement has assigned to the entity through which the MAQI participant participates in
the Qualifying Payment Arrangement. It is most often a short combination of letters and
numbers (for example, H####, E#### or R####). If you are unsure of your Contract #,
please reach out to the point of contact for your Qualifying Payment Arrangement.]
B3. [If yes, for each Qualifying Payment Arrangement] Name of the payer point of contact
for the Qualifying Payment Arrangement (if available):_________________________
B4. [If yes, for each Qualifying Payment Arrangement] Phone number of the payer point of
contact for the Qualifying Payment Arrangement: (if available)________________________
B5. [If yes, for each Qualifying Payment Arrangement] Email address of the payer point of
contact for the Qualifying Payment Arrangement: (if available)________________________
C. What is the number of unique patients to whom the MAQI participant furnished
services that are under the terms of Qualifying Payment Arrangements under this MA
plan during this Snapshot Period?

Services are considered to be under the terms of a Qualifying Payment Arrangement if they
are included in the measures of aggregate expenditures used by the Qualifying Payment
Arrangement. MAQI participants may enter information for any or all of the snapshot
periods. A unique patient may be included in multiple snapshot periods; in other words, a
patient who is included in the first snapshot period should also be included in the second and
third snapshot periods.
C1. First snapshot period (January 1 – March 31):_____________
C2. Second snapshot period (January 1 – June 30):____________
C3. Third snapshot period (January 1 – August 31):_____________
D. What is the total number of unique patients to whom the MAQI participant furnished
services under this MA plan during the snapshot period?
MAQI participants may enter information for any or all of the snapshot periods. The total
number of unique patients submitted for a snapshot period in this section (D) should meet or
exceed the number of unique patients submitted for the same snapshot period in the previous
section (C).
D1. First snapshot period (January 1 – March 31):_____________
D2. Second snapshot period (January 1 – June 30):____________
D3. Third snapshot period (January 1 – August 31):_____________
E. What is the aggregate amount of all payments attributable to the MAQI participant
under the terms of Qualifying Payment Arrangement(s) under this MA plan during the
snapshot period?
MAQI participants may enter information for any or all of the snapshot periods.
C1. First snapshot period (January 1 – March 31):_____________
C2. Second snapshot period (January 1 – June 30):____________
C3. Third snapshot period (January 1 – August 31):_____________
F. What is the aggregate amount of all payments from this MA plan to the MAQI
participant during the snapshot period?
MAQI participants may enter information for any or all of the snapshot periods. The total
amount of payments submitted for a snapshot period in this section (F) should meet or
exceed the amount of payments submitted for the same snapshot period in the previous
section (E).
D1. First snapshot period (January 1 – March 31):_____________

D2. Second snapshot period (January 1 – June 30):____________
D3. Third snapshot period (January 1 – August 31):_____________

SECTION 3: 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]

Data Threshold Submission Form Privacy Act Statement
The Centers for Medicare & Medicaid Services (CMS) is authorized to collect the information
requested on this Form by sections 1833(z)(2)(B)(ii) and (z)(2)(C)(ii) of the Social Security Act
(42 U.S.C. 1395l).
The purpose of collecting this information is to determine whether the MAQI participant is to be
excluded from MIPS.
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
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-XXXX (Expires XX/XX/XXXX). The time
required to complete this information collection is estimated to average 5 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. ****CMS Disclosure**** Please do not send applications, claims,
payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that
any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on
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]