Crosswalk - Threshold Data Submission Form

Revisions to MAQI Threshold Data Submission Form - CMS-10673
Issue
#

Page
#
1

Purpose.

Modify the second paragraph to
be consistent with internal
documents – delete and add
language.

2

5

3

5

Qualifying
Payment
Arrangement
Participation
Data – Section 2
Qualifying
Payment
Arrangement
Participation

1

Section

Action to be Performed

Changes to the Form

Reason for the Change
Revised for clarification purposes,
and to align with internal
documents.

Insert “furnished services” and
delete “bills”

Deleted “The MAQI Demonstration (“the
Demonstration”) allows participants to receive
waivers from MIPS reporting and payment
consequences for a given year if they participate
to a certain degree in Advanced Alternative
Payment Models (Advanced APMs) through
Medicare fee-for-service (FFS) and Qualifying
Payment Arrangements through Medicare
Advantage (MA).” and inserted “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.”
Replaced “bills” with “furnished services” in the
first sentence.

Change “Model participation ID”
to “Contract Number”

Replaced “Model Participation ID” with “Contract
#” on line one.

Revised for clarification purposes.

1

Revised for clarification purposes.

4

5

5

8

Data – Section 2:
B2.
Qualifying
Payment
Arrangement
Participation
Data – Section 2:
B2.
Certification
Statement –
Section 3: Third
Party …

Identify the specific data needed
in the help bubble test.

Inserted H#, and R#; and deleted V#. Also replaced
“Model Participation ID” with “Contract #” in the
help bubble text.

Revised for clarification purposes.

Delete the previous language and
inserted the appropriate
language.

Replaced the previous language with this:
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.

Revised for clarification purposes.

[DATE, MAQI participant]
6

8

Certification
Statement –
Section 3: Third
party ….

Insert a third party attestation in
Section 3.

Inserted the following language: 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:

2

Revised the certification statement
to align with the QPA form.

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.
7

9

Certification
Statement –
Section 3: Third
party ….

Insert a third party attestation in
Section 3.

[DATE, MAQI participant]
Inserted the following language: 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
3

Revised the certification statement
to align with the QPA form.

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.
8

10

9

1

PRA Disclosure
Statement.
Top right corner
of the Form.

Add the OMB four digit approval
number and the expiration date.
Fill in the OMB approved number
and the expiration date.

[DATE, MAQI participant]
Will need to add OMB approved number and the
expiration date in the PRA Disclosure Statement.
Fill in the OMB approved four digit number and
the expiration number on the top right corner of
the form.

4

Edit to include the OMB approved
number and the expiration date.
To display the OMB approved
number and the expiration date as
required by OMB.