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)

OMB: 0938-1314

IC ID: 233582

Information Collection (IC) Details

View Information Collection (IC)

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

Health Health Care Services

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

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

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.

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