(PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1314 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10621 (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16) Form
CMS-10621 Hardship Exception Application Form Appendix U 2019 Hardship Exception Application Form.docx Form
CMS-10621 Extreme and Uncontrollable Circumstances Application For Appendix V 2019 Extreme and Uncontrollable Circumstances Application Form.docx Form

Information Collection (IC) Details

IC Title:	(PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.1375

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10621	Hardship Exception Application Form	Appendix U 2019 Hardship Exception Application Form.docx		Yes	Yes	Fillable Fileable
Form	CMS-10621	Extreme and Uncontrollable Circumstances Application Form	Appendix V 2019 Extreme and Uncontrollable Circumstances Application Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Quality Payment Program (QPP), System No. 09–70– 0539	FR Citation: 83 FR 6587

Number of Respondents: 30,620	Number of Respondents for Small Entity: 30,620

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	30,620	24,579	6,041
Annual IC Time Burden (Hours)	7,655	6,145	1,510
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.