Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 26)

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⚠️ Notice: This information collection may be referencing outdated material.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 Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 26) Form
CMS-10621 Submission Form for Requests for Qualifying Alternative Appendix L All-Payer QP Data Submission Form.docx Form
Appendix M All-Payer QP Data Submission Form Crosswalk.docx Crosswalk IC Document

Information Collection (IC) Details

IC Title:	Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 26)	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	CMS-10621	Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option	Appendix L All-Payer QP Data 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: 551	Number of Respondents for Small Entity: 551

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	551	242	309
Annual IC Time Burden (Hours)	2,755	1,210	1,545
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Appendix M All-Payer QP Data 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.