Threshold Data Submission Crosswalk

Revisions to 2019 MAQI Threshold Data Submission Form - CMS-10673; OMB 0938-1354
Issue
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1

Page
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1

Heading

2

2

Purpose

3

3

4

4

Section 1 B:
MAQI
Participant
Information
Section 1 B:
under TIN Level
Entity.

5

5-6

6

6

Section

Section 2 C and
D

Action to be Performed
Add the previously
approved OMB number.

Revise the submission date to
align with internal
documents.
Insert TIN level language.

Delete #3: “List the first
name(s) and NPIs of each
clinician that can bill through
the TIN”
Revise the questions to
capture needed information
and to align with internal
documents.

Section 2 E and F Revised questions C and D to
capture needed information
and deleted questions E and
F.

Changes to the Form

Reason for the Change

Added the already approved OMB number: OMB
0938-1354.

Revised to align with internal
documents.

Inserted this “Taxpayer Identification Number (TIN):
_________________ under which Eligible Clinicians bills.
[Drop down if they are billing under more than one TIN.]”
to align with internal documents.
Deleted language for clarification, and to align with internal
documents.

Revised for clarification, and to
align with internal documents.

Updated the data submission date to allow participants
more time for the application process.

Clarified (revised) the following questions:
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)?
D. What are the aggregate payments made to the MAQI
PARTICIPANT under the terms of each MAO contract during
the Determination Period(s)?
Deleted the following questions:
E. What is the aggregate payments made to the MAQI
PARTICIPANT under the terms of all of the MAQI
PARTICIPANT’s Qualifying Payment Arrangements
plan during the Determination Period(s)?

1

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

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

Revised (deleted) for
clarification purposes, and to
align with internal documents.

Issue
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Page
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Section

Action to be Performed

7

All

All Sections

Change Group and add Entity

8

All

All Sections

Minor revisions to wording

9

All

All Sections

Clarify NPI TIN participation
language.

Changes to the Form
F. What is the aggregate of all MAO payments to the
MAQI PARTICIPANT during the Determination
Period(s)?
Changed Group/TIN level to TIN level Entity for clarification
and to align with internal documents.
Updated certain wording in the document to align with
Participation Agreement language and internal documents.
Clarified NPI TIN level participation to align with internal
documents.

2

Reason for the Change

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