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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10621 Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option	Form	Modified	Available
Form CMS-10621 Measures under Consideration 2019, Data Template for Candidate Measures	Form and Instruction	Modified	Available
Form CMS-10621 Data Template for Candidate Measures	Form and Instruction	Modified	Available
Form CMS-10621 Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submission Form)	Form	Modified	Available
Form CMS-10621 Promoting Interoperability Performance Category: Call for Measures Submission Form	Form and Instruction	Modified	Available
Form CMS-10621 Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form)	Form and Instruction	Modified	Available
Form CMS-10621 Improvement Activities Performance Category: Call for Activities Submission Form	Form	Modified	Available
Form CMS-10621 Extreme and Uncontrollable Circumstances Application Form	Form	Modified	Available
Form CMS-10621 Hardship Exception Application Form	Form	Modified	Available
Form CMS-10621 2020 Qualified Clinical Data Registry (QCDR) Measure Submission Template	Form	Modified	Available
CMS-10621 - Supporting Statement 0938-1314 - Passback CLEAN.docx	Supporting Statement A	Uploaded 2020-05-26	Available
CMS-10621 Response to Comments.pdf	Supplementary Document	Uploaded 2019-11-22	Available
CMS-10621 - MIPS CY 2020 Supporting Statement B 10-28-19.docx	Supporting Statement B	Uploaded 2019-11-22	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
233582	Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 26)	Form	Modified	Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option
233581	QPP Identity Management Application Process (see SS-A Table 9)		Modified
229086	(Quality Performance Category) Call for Quality Measures (see SS-A Table 15)	Form and Instruction	Modified	Measures under Consideration 2019, Data Template for Candidate Measures
229086	(Quality Performance Category) Call for Quality Measures (see SS-A Table 15)	Form and Instruction	Modified	Data Template for Candidate Measures
229075	Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 25)	Form	Modified	Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submission Form)
229074	(PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 19)	Form and Instruction	Modified	Promoting Interoperability Performance Category: Call for Measures Submission Form
227511	(Physician Compare) Opt Out for Voluntary Participants (see SS-A Table 27)		Modified
227509	Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 24)	Form and Instruction	Modified	Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form)
227507	(Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 22)	Form	Modified	Improvement Activities Performance Category: Call for Activities Submission Form
227506	(PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)	Form	Modified	Extreme and Uncontrollable Circumstances Application Form
227506	(PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)	Form	Modified	Hardship Exception Application Form
227505	(Quality Performance Category) Group Registration for CMS Web Interface (see SS-A Table 14)	Instruction	Modified
221786	Partial Qualifying APM Participant (QP) Election (see SS-A Table 23)		Modified
221785	(Improvement Activities Performance Category) Data Submission (see SS-A Table 21)		Modified
221784	(PI Performance Category) Data Submission (see SS-A Table 18)		Modified
221782	Self-nomination: QCDR and Qualified Registry (see SS-A Tables 3 and 4)	Form	Modified	2020 Qualified Clinical Data Registry (QCDR) Measure Submission Template
221782	Self-nomination: QCDR and Qualified Registry (see SS-A Tables 3 and 4)	Instruction	Modified
221781	(Quality Performance Category) CMS Web Interface Submission Type (see SS-A Table 13)		Modified
221780	(Quality Performance Category) eCQM Collection Type (see SS-A Table 12)		Modified
221779	(Quality Performance Category) QCDR/MIPS CQM Collection Type (see SS-A Table 11)		Modified
221777	(Quality Performance Category) Claims Collection Type (see Table SS-A 10)		Modified

ICR Details

OMB Control No: 0938-1314	ICR Reference No: 201911-0938-009
Status: Historical Active	Previous ICR Reference No: 201812-0938-013
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Quality Payment Program/Merit-Based Incentive Payment System (MIPS) (CMS-10621)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/04/2020
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/25/2019
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2022	36 Months From Approved	01/31/2022
Responses	475,198	0	644,144
Time Burden (Hours)	2,937,891	0	5,109,042
Cost Burden (Dollars)	0	0	0

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Abstract: Section 1848(q) of the Social Security Act, as amended by section 101 of the Medicare Access and CHIP Reauthorization Act of 2015, authorizes the establishment of a Merit-based Incentive Payment System (MIPS) for eligible clinicians. Beginning in CY 2017, eligible clinicians are required to collect and submit data on four performance categories to CMS (quality, cost, advancing care information and improvement activities). This program replaces and consolidates portions of the PQRS, Value-based Modifier, and the Medicare EHR Incentive Program. The Act also establishes a second track, Advanced Alternative Payment Models (APMs) for clinicians to participate in instead of MIPS.

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Authorizing Statute(s): US Code: 42 USC 1395w-4 Name of Law: Medicare Access and CHIP Reauthorization Act of 2014
  

Citations for New Statutory Requirements: US Code: 42 USC 1395w-4 Name of Law: Medicare Access and CHIP Reauthorization Act of 2014

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AT72	Final or interim final rulemaking	84 FR 62998	11/15/2019

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 40482	08/14/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 62998	11/15/2019
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 18

table that charts list of burden

IC Title	Form No.	Form Name
(Improvement Activities Performance Category) Data Submission (see SS-A Table 21)
(Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 22)	CMS-10621	Improvement Activities Performance Category: Call for Activities Submission Form
(PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 19)	CMS-10621	Promoting Interoperability Performance Category: Call for Measures Submission Form
(PI Performance Category) Data Submission (see SS-A Table 18)
(PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)	CMS-10621, CMS-10621	Hardship Exception Application Form ,   Extreme and Uncontrollable Circumstances Application Form
(Physician Compare) Opt Out for Voluntary Participants (see SS-A Table 27)
(Quality Performance Category) CMS Web Interface Submission Type (see SS-A Table 13)
(Quality Performance Category) Call for Quality Measures (see SS-A Table 15)	CMS-10621, CMS-10621	Data Template for Candidate Measures ,   Measures under Consideration 2019, Data Template for Candidate Measures
(Quality Performance Category) Claims Collection Type (see Table SS-A 10)
(Quality Performance Category) Group Registration for CMS Web Interface (see SS-A Table 14)
(Quality Performance Category) QCDR/MIPS CQM Collection Type (see SS-A Table 11)
(Quality Performance Category) eCQM Collection Type (see SS-A Table 12)
Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 25)	CMS-10621	Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submission Form)
Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 24)	CMS-10621	Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form)
Partial Qualifying APM Participant (QP) Election (see SS-A Table 23)
QPP Identity Management Application Process (see SS-A Table 9)
Self-nomination: QCDR and Qualified Registry (see SS-A Tables 3 and 4)	CMS-10621	2020 Qualified Clinical Data Registry (QCDR) Measure Submission Template
Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 26)	CMS-10621	Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	475,198	644,144	0	-168,946	0	0
Annual Time Burden (Hours)	2,937,891	5,109,042	0	-2,170,343	-808	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: All burden changes are adjustments except for changes to §414.1400 (QCDR self nomination) which are comprised of revisions (-1,488 hours) and burden adjustments (-304 hours); and changes to the Call for Quality Measures which are comprised of revisions (+28 hours) and burden adjustments (-504 hours).

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/25/2019

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