Crosswalk

All-Payer QP Data Submission Form

2019 Finalized vs. 2020 Finalized

Burden Impact: There are no impacts to burden as a result of any changes to this form from the previous version.

Page	Line	Final Rule 2019	Final Rule 2020	Reason for Change
1	29	Payment 2024 and later	Performance Payment Year 2019 2020 2021 2022 2023 2024 and later	Edited for clarity.
1	38		QP Payment Amount Threshold	Edited for clarity.
1	32	QP Payment Amount Threshold		Edited for clarity.
1	38	Total N/A N/A 50% 50% 75%	Total 50% 50% 75% 75% 75%	Edited for clarity.
1	38	Total		Edited for clarity.
1	38	Medicare Minimum		Edited for clarity.
1	38	Total N/A N/A 40% 20% 40%	Total 40% 40% 40% 40% 40%	Edited for clarity.
2	9		Performance	Edited for clarity.
2	10	Payment		Edited for clarity.
2	9	2024 and later		Edited for clarity.
2	13	N/A N/A 35% 35% 50% 50%	Total 35% 35% 50% 50% 50%	Edited for clarity.
2	13	Total		Edited for clarity.
2	13	Medicare Minimum		Edited for clarity.
2	12	Total N/A N/A 25% 10% 25%	Total 25% 25% 35% 35% 35%	Edited for clarity.
3	21	[	,	Edited for clarity.
3	21	/	, or	Edited for clarity.
3	23	To determine whether the [		Edited for clarity.
3	23	Clinician/ TIN/	Clinicians, TINs, or	Edited for clarity.
3	24	Entities whose primary practice is in any of the following locations, are required to submit their		Edited for clarity.
3	25	Entity] meets the criteria for		Edited for clarity.
3	25		payments and patient data.	Edited for clarity.
3	26	exclusion, please refer to the look-up tool at [hyperlink]. If the [		Edited for clarity.
3	27	Clinician/TIN/	Clinicians, TINs, and	Edited for clarity.
3	27	Entity] does not meet the Title	Entities may exclude their Title	Edited for clarity.
3	28	payment and patient data		Edited for clarity.
3	28	exclusion criteria listed in the look-up tool, Title XIX data must be included in this Form		Edited for clarity.
3	31		XIX Table: Massachusetts All Counties Ohio All Counties Tennessee All Counties Washington All Counties Oregon Benton, Lincoln, Linn Counties	Alignment with current year.
4	42	[Eligible Clinicians/TINs/APM Entities] 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 relevant payers must be included for whichever Snapshot Period(s) the [Eligible Clinician/TIN/APM Entity] chooses to submit.		Edited for clarity.
4	4	[If submitted by the Eligible Clinician] The Eligible Clinician or an authorized agent of the Eligible Clinician may submit the Form on behalf of the Eligible Clinician. In submitting the Form, the submitter attests that he or she is qualified to make the assertions contained herein as the Eligible Clinician or an agent of the Eligible Clinician and that the assertions contained herein are true and accurate with respect to this Form. [If submitted by the TIN		Edited for clarity.
5	16	[If submitted by the APM Entity] The representative who submits the Form for the APM Entity must be an authorized agent of the APM Entity. In submitting the Form, the submitter attests that he or she is qualified to make the assertions contained herein as an agent of the APM Entity and that the assertions contained herein are true and accurate with respect to this Form. [If determination is requested at the Eligible Clinician level] CMS will review the Other Payer Advanced APM participation information in this Form to determine whether the Eligible Clinician meets the QP thresholds. If incomplete information is submitted and/or more information is required to make a determination, CMS will notify the Eligible Clinician and request the additional information that is needed. Eligible Clinicians must return the requested information no later than 5 business days from the notification date. If the Eligible Clinician does not submit sufficient information within this time period, the Eligible Clinician will not be assessed for QP status through the All Payer Combination Option for that Performance Period. These determinations are final and not subject to reconsideration. [If determination is requested at the TIN level] CMS will review the Other Payer Advanced APM participation information in this Form to determine whether the Eligible Clinicians billing under the TIN meet the QP thresholds. If incomplete information is submitted and/or more information is required to make a determination, CMS will notify the TIN point of contact and request the additional information that is needed. The TIN point of contact must return the requested information no later than 5 business days from the notification date. If the TIN point of contact does not submit sufficient information within this time period, Eligible Clinicians participating in the TIN will not be assessed for QP status through the All Payer Combination Option for that Performance Period. These determinations are final and not subject to reconsideration. [If determination is requested at the APM Entity level] CMS will review the Other Payer Advanced APM participation information in this Form to determine whether the Eligible Clinicians participating in the APM Entity meet the QP thresholds. If incomplete information is submitted and/or more information is required to make a determination, CMS will notify the APM Entity and request the additional information that is needed. APM Entities must return the requested information no later than 5 business days from the notification date. If the APM Entity does not submit sufficient information within this time period, the Eligible Clinicians participating in the APM Entity would not be assessed for QP status through the All Payer Combination Option for that Performance Period. These determinations are final and not subject to reconsideration.		Edited for clarity.
5	18	- QPP All-Payer FAQs		Edited for clarity.
5	27	[Eligible Clinician/TIN/APM Entity]	Submitter Type Section 2: Participant	Edited for clarity.
5	28	2	3	Edited for clarity.
5	29	3	4	Edited for clarity.
5	30	[Eligible Clinicians/TINs/APM Entities] must complete Sections 1 and 3. Section 2 includes options for submitting data for any of the three Snapshot Periods. [Eligible Clinicians/TINs/APM Entities] may submit information for any or all of the three Snapshot Periods. It is strongly recommended, though not required, that [Eligible Clinicians/TINs/APM Entities] submit both patient count and payment amount information for whichever Snapshot Period(s) they choose.		Edited for clarity.
6	1		Submitter Type Select one of the following: APM Entity [CHECK BOX] APM Entity means an entity that participates in an APM or payment arrangement with a non-Medicare payer through a direct agreement or through Federal or State law or regulation. Eligible Clinician(s) [CHECK BOX] Eligible clinician means "eligible professional" as defined in section 1848(k)(3) of the Act, as identified by a unique TIN and NPI combination and, includes any of the following: ---I. A physician. ---ii. A practitioner described in section 1842(b)(18)(C) of the Act. ---iii. A physical or occupational therapist or a qualified speech-language pathologist. ---iv. A qualified audiologist (as defined in section 1861(ll)(3)(B) of the Act). TIN Level [CHECK BOX	Edited for alignment with finalized requirement.
6	25		Note: Only participants in the Medicare Shared Savings Program may submit data at the TIN level for performance year 2019. SECTION 2: Participant	Edited for clarity.
6	45		Business	Edited for clarity.
7	17		Confirm NPI: __________________________________	Edited for clarity.
7	18	Advanced APM(s) in which Eligible Clinician participates [DROP DOWN LIST, allow multiple selections] 4a. [For each Advanced APM selected] Model participation ID (if applicable):______________ [Help bubble text: This refers to the unique identifier that the Advanced APM has assigned to the APM Entity through which the Eligible Clinician 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.] 4b. [For each Advanced APM selected] TIN through which Eligible Clinician participates in the Advanced APM:_________________ 4c. [For each Advanced APM selected] Name of the point of contact (e.g. Project Officer) for the APM Entity at CMS (optional):____________________		Edited for alignment with finalized requirement.
7	37		Legal Entity Name	Edited for alignment with finalized requirement.
7	39		Tax Idenfication Number: __________________________ Retype TIN:______________________________	Edited for alignment with finalized requirement.
8	41	NPIs that bill through the TIN: ___________________________ This form should only be completed at the TIN level if all NPIs that bill through the TIN participate in an Advanced APM through the TIN. Advanced APM(s) in which the TIN participates [DROP DOWN LIST, allow multiple selections] 3a. [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 TIN 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.] 3b. [For each Advanced APM selected] Name of the point of contact (e.g. Project Officer) for the APM Entity at CMS (optional):____________________		Edited for alignment with finalized requirement.
8	21		Retype TINs:_______________________________________________	Edited for alignment with finalized requirement.
8	21	Advanced APM(s) in which the APM Entity participates [DROP DOWN LIST, allow multiple selections] 3a. Model participation ID:_____________________ [Help bubble text: This refers to the unique identifier that the Advanced APM has assigned to the APM Entity. 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.] 3b. [For each Advanced APM selected] Name of the point of contact (e.g. Project Officer) for the APM Entity at CMS (optional):____________________		Edited for alignment with finalized requirement.
8	35	[	:	Edited for clarity.
8	35	to include at the bottom of this section for APM Entities]		Edited for clarity.
9	1	2	3	Edited for clarity.
9	7		Information on Medicare FFS or participation in Medicare Advanced APMs should not be submitted.	Edited for clarity.
9	10	To determine whether the [Eligible Clinician/ TIN/ APM Entity] meets the criteria for Title XIX exclusion, please refer to the look-up tool at [hyperlink]. If the [Eligible Clinician/TIN/APM Entity] does not meet the Title XIX exclusion criteria listed in the look-up tool, Title XIX data must be included in this Form. [		Edited for clarity.
9	15	/	,	Edited for clarity.
9	15	/	, and	Edited for clarity.
9	15	] may	must	Edited for clarity.
9	15	to submit information for any or all of the	a specific	Edited for clarity.
9	17	Periods;	Period for submitting data. This period must match the same timeframe for the Medicare Advanced APM in which	Edited for clarity.
9	17	.	participate	Edited for clarity.
9	17	are not required to submit information for all three Snapshot Periods.		Edited for clarity.
9	24		Snapshot Period Please select the Snapshot Period for which you are submitting data for the 2019 QP Performance Period. Note, this Snapshot Period should be the same as the Medicare FFS Snapshot Period data you choose to be used in the All-	Edited for alignment with finalized requirement.
9	27	Add a		Edited for alignment with finalized requirement.
9	27		QP Calculation. If you have not achieved QP status based on any Medicare snapshot, we will assess your performance using the All-Payer Combination Option base on the snapshot you select: [Drop down menu] 1. January – March 2. January – June 3. January – August Work Sheet for Data Submission [Instructions provided for downloading and uploading a Excell Spreadsheet for entering required data.	Edited for alignment with finalized requirement.
9	37	+ [Button] [		Edited for alignment with finalized requirement.
9	37	below	payment arrangement with each	Edited for alignment with finalized requirement.
9	38	(		Edited for alignment with finalized requirement.
9	38	each discrete	discrete from which	Edited for alignment with finalized requirement.
9	38	), and there is no limit on the number of payers (plans) for which	have received payment for serviced during the snapshot period selected.] In the Participant Identification section of the QPP All Payer Submission Form, you selected whether your submission is at the APM Entity, Eligible Clinician, or TIN level. In Section [#], you indicated the “Snapshot Period” for which you are submitting data. Data reported in this worksheet MUST be reported at the level you indicated in the “Submitter Type” field and for the “Snapshot Period” you indicated in Section [#]. For example, if you selected “TIN level” as your submitter type and the “Second Snapshot” as the period for which you are submitting data, please	Edited for alignment with finalized requirement.
10	2	may		Edited to clarify.
10	2	in all payment arrangements under which your TIN received payments during the Second Snapshot (January 1, 2019-June 30, 2019). This form may be completed by [the eligible clinician/an eligible clinician in your TIN/an eligible clinician in your APM Entity] or by an authorized individual on behalf of the [eligible clinician/TIN/APM Entity. Examples of authorized individuals include (but are not limited to) practice manager, financial analyst/ manager, and accountant. Note: The TIN reporting option may only be used by TINs participating in the Medicare Shared Savings Program. The following		Edited for alignment with finalized requirement.
10	13	. After the information below has been entered for	must be submitted in	Edited for alignment with finalized requirement.
10	14	payer, display a chart summarizing the payers entered so far, and allow users to press this button again to add another payer]	row of the worksheet for which an entry is made:	Edited for alignment with finalized requirement.
10	19	Payer Name:___________________________	Payment Arrangement Name [Drop down list of previously determined Other Payer Advanced APMs; or free text]:___________________________	Edited for alignment with finalized requirement.
10	23	Type of Payer [drop-down: Medicare health plan, Medicaid, Commercial, Other]	Payment Arrangement Identifier [drop-down: Identifiers of previously determined Other Payer Advanced APMs; or free text] _____________________________	Edited for alignment with finalized requirement.
10	26		Payer Name:______________________________ Type of Payer (e.g, Medicare Advantage, Medicaid):_________________________ Payment Arrangement Point of Contact Name:_____________________________ Payment Arrangement Point of Contact Phone: ______________________________
11	33		Total Payments:____________________________________________________ Enter the total payments received (in dollars) under the terms of the payment arrangement you entered in column A. The data entered into this field should be based on the "Snapshot Period" you selected in Section [#] of the QPP All Payer Submission Form and at the same level as the Participant Identification you selected in the QPP All Payer Submission Form. For example, if you indicated in the QPP All Payer Submission Form that your submission was for the Second Snapshot and your Submitter Type was “TIN level,” the dollar amount you enter in this field should be the total payments that the TIN received under the payment arrangement during the Second Snapshot (January 1, 2019-June 30, 2019). Drug costs should be included in the reported total payments IF the payment arrangement includes drug costs. If drug costs are not included in the payment arrangement, drug costs should not be reported as part of total payments. Total Patients:________________________________ On the Data Collection Worksheet tab, enter the number of unique patients furnished services under the terms of the payment arrangement you entered in column A. The data entered into this field should be based on the "Snapshot Period" you selected in Section [#] of the QPP All Payer Submission Form and at the same level as the “Submitter Type” you selected in the QPP All Payer Submission Form. For example, if you indicated in the QPP All Payer Submission Form that your submission was for the Second Snapshot and your Submitter Type was “TIN level,” the number you enter in this field should be the total number of unique patients to whom the TIN furnished services under the payment arrangement during the Second Snapshot (January 1, 2019-June 30, 2019). To determine which patients should be counted, please include only those that are included in the measure of total payments you reported for the payment arrangement. Note that this is a count of unique patients NOT a count of unique visits (i.e., one patient with two visits under the same payment arrangement will be counted only once.)	Edited for alignment with finalized requirement.
13	21	Did the [Eligible Clinician/TIN/APM Entity] participate in an Other Payer Advanced APM with this plan during the Performance Period (January 1 – August 31)? [Y/N] C1. [If yes] Name of Other Payer Advanced APM: Note: In order to select a payment arrangement as an Other Payer Advanced APM in this Form, that payment arrangement must have been submitted for an Other Payer Advanced APM determination through either the Payer- or Eligible Clinician-Initiated Processes. If your payment arrangement is not in this list, please submit an Other Payer Advanced APM determination request using the Eligible Clinician-Initiated Process. The deadline to submit Other Payer Advanced APMs through the Eligible Clinician-Initiated Process is November 1; you may not submit additional determination requests after that date. Upon submitting the Other Payer Advanced APM determination request for a payment arrangement, that payment arrangement will appear in this list. Please note that inclusion in this list does not indicate that a payment arrangement has been determined to be an Other Payer Advanced APM; it merely indicates that it has been submitted for an Other Payer Advanced APM determination. You may select more than one Other Payer Advanced APM per plan. [drop-down of Other Payer Advanced APMs] C3. [If yes, for each Other Payer Advanced APM] Name of the payer point of contact for the Other Payer Advanced APM (if available):_________________________ C4. [If yes, for each Other Payer Advanced APM] Phone number of the payer point of contact for the Other Payer Advanced APM: (if available)_________________________ C5. [If yes, for each Other Payer Advanced APM] Email address of the payer point of contact for the Other Payer Advanced APM: (if available)_________________________ [If no: no follow-up question; skip question C and go straight to question E] [If answer to C was yes] What is the number of unique patients to whom the [Eligible Clinician/TIN/APM Entity] furnished services that are under the terms of this Other Payer Advanced APM during the Snapshot Period? Services are considered to be under the terms of the Other Payer Advanced APM if they are included in the measures of aggregate expenditures used by the Other Payer Advanced APM. [Eligible Clinicians/TINs/Advanced APMs] may enter information for any or all of the Snapshot Periods. A unique patient may be included in multiple Snapshot Periods; in other words, a patient who is included in the first Snapshot Period should also be included in the second and third 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):_____________ What is the total number of unique patients to whom the [Eligible Clinician/TIN/APM Entity] furnished services under this payer during the Snapshot Period? [Eligible Clinicians/TINs/Advanced APMs] may enter information for any or all of the Snapshot Periods. The total number of unique patients submitted for a Snapshot Period in this section (E) should meet or exceed the number of unique patients submitted for the same Snapshot Period in the previous section (D). E1. First Snapshot Period (January 1 – March 31):_____________ E2. Second Snapshot Period (January 1 – June 30):____________ E3. Third Snapshot Period (January 1 – August 31):_____________ [If answer to C was yes] What is the aggregate amount of all payments from this payer attributable to the [Eligible Clinician/TIN/APM Entity] under the terms of the Other Payer Advanced APM during the Snapshot Period? [Eligible Clinicians/Advanced APMs] may enter information for any or all of the Snapshot Periods] F1. First Snapshot Period (January 1 – March 31):_____________ F2. Second Snapshot Period (January 1 – June 30):____________ F3. Third Snapshot Period (January 1 – August 31):_____________ What is the aggregate amount of all payments from this payer to the [Eligible Clinician/TIN/APM Entity] during the Snapshot Period? [Eligible Clinicians/TINs/Advanced APMs] may enter information for any or all of the Snapshot Periods. The total amount of payments submitted for a Snapshot Period in this section (G) should meet or exceed the amount of payments submitted for the same Snapshot Period in the previous section (F) G1. First Snapshot Period (January 1 – March 31):_____________ G2. Second Snapshot Period (January 1 – June 30):____________ G3. Third Snapshot Period (January 1 – August 31):_____________		Edited for alignment with finalized requirement.
14	2	3		Edited to clarify.
14	10	the knowing omission, misrepresentation	any person who knowingly files a statement of claim containing any false, incomplete	Edited to clarify.
14	10	falsification of any	misleading	Edited to clarify.
14	11	contained in this document or in any communication supplying information to CMS	,	Edited to clarify.
14	12	punished by	guilty of a	Edited to clarify.
14	13	, or administrative		Edited to clarify.
14	13	, including fines, civil damages and/or imprisonment	act punishable under Federal and state law and may be subject to	Edited to clarify.