(Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 22)

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⚠️ Notice: This information collection may be referencing outdated material.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 (Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 22) Form
CMS-10621 Improvement Activities Performance Category: Call for Ac Appendix R 2020 IA Call for Activities Submission Form.docx Form
Appendix S 2020 IA Call for Activities Submission Form Crosswalk.docx Crosswalk IC Document

Information Collection (IC) Details

IC Title:	(Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 22)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.1360

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10621	Improvement Activities Performance Category: Call for Activities Submission Form	Appendix R 2020 IA Call for Activities Submission 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: 31	Number of Respondents for Small Entity: 31

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	31	-94	125
Annual IC Time Burden (Hours)	62	-188	250
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Appendix S 2020 IA Call for Activities Submission Form Crosswalk.docx	11/22/2019

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