Qualifying Arrangement Crosswalk

Revisions to 2019 MAQI Qualifying Arrangement Form - CMS-10673; OMB 0938-1354
Issue
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Page
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Heading

Add previously approved
OMB number.

Added the already approved OMB number: OMB 09381354.

Revised to align with internal
documents.

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2

Deadline

Modify submission date

Modified submission date from September 1, 2019 through
October 31 to August 1, 2019 through October 2, 2019.

Revised to allow participants
more time for the submission
process, and to align with
internal documents.

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Section

Action to be Performed

Throughout the
document.
Section 1 B:
under TIN Level
Entity
submitting.
Section 2 A:
General
Information.
Section 2 B

Change “Group” and replace
with “Entity”
Delete #3: “List the first
name(s) and NPIs of each
clinician that can bill through
the TIN”
Insert a link for payment
arrangement reference and
updated the language.
Delete language, and revise
remaining sentence for
clarity.

Section 2 B:
Payment
Arrangement
Documentation.

Insert “contract number”
information.

Changes to the Form

The determination date is also changed from
December/January 2019 to December/January 2020.
Changed Group/TIN level to TIN level Entity throughout the
document to align with internal documents.
Deleted language for clarification, and to align with internal
documents.

Reason for the Change

Revised for clarification and to
align with internal documents.
Revised for clarification, and to
align with internal documents.

Inserted the QPP link:
(https://qpp.cms.gov/about/resource-library) and updated
the language for clarification.
Deleted this: [For Eligible Clinicians and Authorized
Representatives] Does the payment arrangement
documentation apply to all of the eligible clinicians' NPIs
that you have listed? [yes/no].
Please provide contract numbers. If no, please add
additional information for each eligible clinician. [additional
text fields for additional documentation]

Updated section with link and
revised language for
clarification.
Revised for clarification, and to
align with internal documents.

Inserted “please provide contract numbers” for clarity.

Updated language for
clarification and to align with
internal documents.

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