Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 24)

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

OMB: 0938-1314

IC ID: 227509

Information Collection (IC) Details

View Information Collection (IC)

Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 24)
 
No Modified
 
Mandatory
 
42 CFR 414.1440

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10621 Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form) Appendix H Payer Initiated Submission Form (12-05-19) CLEAN.docx Yes Yes Fillable Fileable

Health Health Care Services

Quality Payment Program (QPP), System No. 09–70– 0539  83 FR 6587

110 110
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 110 0 -105 0 0 215
Annual IC Time Burden (Hours) 1,100 0 -1,050 0 0 2,150
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Crosswalk Appendix I Payer Initiated Submission Form Crosswalk (12-05-19).docx 12/10/2019
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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