Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 25)

Quality Payment Program/Merit-Based Incentive Payment System (MIPS) (CMS-10621)

OMB: 0938-1314

IC ID: 229075

Information Collection (IC) Details

View Information Collection (IC)

Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 25)
 
No Modified
 
Mandatory
 
42 CFR 414.1445

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-10621 Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submission Form) Appendix D Clinician Initiated Submission Form (version 2).docx Yes Yes Fillable Fileable

Health Health Care Services

 

150 75
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 150 0 0 75 0 75
Annual IC Time Burden (Hours) 1,500 0 0 750 0 750
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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