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

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⚠️ Notice: This information collection may be referencing outdated material.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 Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 24) Form and Instruction
CMS-10621 Other Payer Requests for Other Payer Advanced Alternativ Appendix H Payer Initiated Submission Form (12-05-19) CLEAN.docx Form and Instruction
Appendix I Payer Initiated Submission Form Crosswalk (12-05-19).docx Crosswalk IC Document

Information Collection (IC) Details

IC Title:	Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 24)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.1440

Information Collection Instruments:

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

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: 110	Number of Respondents for Small Entity: 110

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	110	-105	215
Annual IC Time Burden (Hours)	1,100	-1,050	2,150
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.