Form CMS-10673 MAQI Threshold Data Submission Form

OMB Control Number: 0938-1354
Expires: 10/31/2021

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 annual exclusions from the
Merit-Based Incentive Payment System (“MIPS”) reporting requirements, payment adjustments,
and performance feedback (collectively, the “MIPS exclusions”) under the Medicare Advantage
Qualifying Payment Arrangement Incentive (MAQI) Demonstration. This process is called the
MIPS exclusion determination process.
The MAQI Demonstration will allow participating eligible clinicians to have the opportunity to
receive the MIPS exclusions for a given year if they participate to a sufficient degree in
Qualifying Payment Arrangements with Medicare Advantage Organizations (MAOs) (combined
with participation in Advanced Alternative Payment Models (APMs) with Medicare Fee-forService (FFS), if any) during the performance period for that year, without meeting the criteria to
be Qualifying APM Participants (QPs) or Partial QPs, or otherwise being excluded from MIPS.
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 2 of the year of the Performance Period. CMS will not review Forms submitted
after the Submission Deadline.
Additional Information
CMS will review the Payment Arrangement information provided in this Form, in conjunction
with information reported on the Qualifying Payment Arrangement Form, to determine whether
the MAQI participant meets the conditions to receive the MIPS exclusions. 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 whether they have met the requirements for the MIPS
exclusion as soon as possible after determinations are made.
Instructions for Completing and Submitting this Form
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: Payment Arrangement Data
Section 3: Certification Statement

MAQI participants must complete all sections. 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: ____________

Are you an Eligible Clinician, or an Authorized Representative, submitting this information on
behalf of an individual clinician(s)? [check box].
Are you submitting on behalf of your clinicians at the TIN Level Entity? [check box]. [NOTE:
This check box should only be completed at the TIN Level Entity when NPIs that bill through
the TIN have reassigned their billing to that TIN].
B.

MAQI Participant Information

[Eligible Clinician and information submitted by the Authorized Representative]
1. List the first name(s), last name(s), and NPI(s) of the eligible clinician(s).
[Text box; Add button for more than one Eligible Clinician that the Authorized
Representative is submitting for]
2. Taxpayer Identification Number (TIN): _______________under which Eligible
Clinician bills. [Drop down if they are billing under more than one TIN.]

[TIN Level Entity]
[NOTE: This form should only be completed at the TIN Level Entity when NPIs that bill through
the TIN have reassigned their billing to that TIN.]
1. List the TIN Level Entity Legal Name participating in the payment arrangement:
_______________________________________

2. Taxpayer Identification Number (TIN):_______________________

C.

Advanced APM(s)
1. Advanced APM(s) in which MAQI participant participates [DROP DOWN LIST,
allow multiple selections]
1a. [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.]
2b. [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: Payment Arrangement Data
Information for all Medicare Advantage plans through which the MAQI participant furnished
services must be included. [Eligible Clinician/Authorized Representative or TIN Level Entity]
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 Medicare Advantage 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:___________________________ [Add button for additional plan name]
B. Did the [Eligible Clinician or TIN Level Entity] participate in a Payment Arrangement
with this plan during the Performance Period (January 1 – August 31)? [Y/N] [Must
answer these questions for each plan listed]
B1. [If yes, Name(s) of Payment Arrangement(s)]: Note: the name listed here must match the
name that the [Eligible Clinician or TIN Level Entity] participant used when submitting the
Payment Arrangement determination request to CMS. You may select more than one
Payment Arrangement per plan. [free text]:_______________________
B2. [If yes, for each 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 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 Payment Arrangement.]
B3. [If yes, for each Payment Arrangement] Name of the payer point of contact for the
Payment Arrangement (if available):_________________________
B4. [If yes, for each Payment Arrangement] Phone number of the payer point of contact for
the Payment Arrangement: (if available)________________________
B5. [If yes, for each Payment Arrangement] Email address of the payer point of contact for
the Payment Arrangement: (if available)________________________
C. What is the number of Medicare beneficiaries to whom the MAQI PARTICIPANT or,
in the case of a MAQI PARTICIPANT that is a TIN Level Entity, the MAQI
PARTICIPANT’s Eligible Clinicians furnished services under each MAO contract
during the Determination Period(s)?
[Eligible Clinician/Authorized Representative or TIN Level Entity] 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):_____________
D. What are the aggregate payments made to the MAQI PARTICIPANT under the terms
of each MAO contract during the Determination Period(s)?

[Eligible Clinician/Authorized Representative or TIN Level Entity] participants may enter
information for any or all of the snapshot periods.
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
I have read the contents of this submission. By submitting this Form, I certify that I am legally
authorized to bind the [Eligible Clinician/Authorized Representative or TIN Level Entity]. 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.
I agree [Check box]
AUTHORIZED INDIVIDUAL NAME, TITLE, [ELIGIBLE CLINICIAN/TIN/TIN Level
Entity]

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 0938-1354 (Expires 10/31/2021). 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]