Crosswalk: 2020 Qualified Registry Fact Sheet

Qualified Registry Self-Nomination Fact Sheet
CY 2020 Final versus CY 2021 Proposed
Burden impact: The changes to this self-nomination fact sheet reflect proposals in the CY2021
Physician Fee Schedule (PFS) Proposed Rule for the Quality Payment Program and result in an
estimated increase of 3 hours for each respondent required to submit a Corrective Action Plan
(CAP).
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Change #1:
Location: Page 1
Reason for Change:
Alignment with current year
CY 2020 Final Rule text:
Section Header2020 Qualified Registry Fact Sheet
CY 2021 Proposed Rule text:
Section Header2021 Qualified Registry Fact Sheet
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Change #2:
Location: Page 1
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
Section Header - Overview
To become a Qualified Registry for the Merit-based Incentive Payment System
(MIPS) under the Quality Payment Program, you must self-nominate and
successfully complete a qualification process.
CY 2021 Proposed Rule text:
Section Header - Overview
To become a Qualified Registry for the Merit-based Incentive Payment System
(MIPS) program under the Quality Payment Program, you must self-nominate and
successfully complete a qualification process.
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Change #3:
Location: Page 1
Reason for Change:
Edited for alignment with finalized
requirements,
CY 2020 Final Rule text:
Section Header - When is the self-nomination period?
July 1 – September 3 of the year prior to the applicable performance period. The
Self-Nomination Period will promptly open at 10:00 am ET on July 1st and close

at 8:00 pm ET on September 3rd. Self-Nominations submitted after the deadline
will not be considered.
CY 2021 Proposed Rule text:
Section Header - When is the self-nomination period?
July 1 – September 1 of the year prior to the applicable performance period. The selfnomination Period will promptly open at 10 a.m. (Eastern Time) ET on July 1st and close
at 8 p.m. ET on September 1, 2020. Self-Nominations submitted after the deadline will not be
considered.
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Change #4:
Location: Page 1
Reason for Change:
Edited for alignment with finalized requirements, edited for
clarity
CY 2020 Final Rule text:
Section Header - Tips for Successful Self-Nomination:
1. To become qualified for a given performance period, the vendor must have at least 25
participants by January 1 of the year prior to the applicable performance period. These
participants do not need to use the Qualified Registry to report MIPS data to us; rather, they
need to submit data to the Qualified Registry for purposes of quality improvement.
2. You must provide all required information at the time of self-nomination, and before the
close of the self-nomination period via the CMS Quality Payment Program portal
(https://qpp.cms.gov/login) for CMS consideration.
3. Self-nomination is an annual process. If you want to qualify as a Qualified Registry for a given
performance period, you will need to self-nominate for that performance period. Qualification
and participation in a prior program year does not automatically qualify a vendor for
subsequent MIPS performance periods.
A simplified self-nomination form is available to reduce the burden of self-nomination for those
existing Qualified Registries that have previously participated in MIPS and are in good
standing (CMS did not take remedial action against or terminate the registry as a third party
intermediary).
A simplified self-nomination form is available to reduce the burden of self-nomination for those
existing QCDRs that have previously participated in MIPS and are in good standing (CMS did
not take remedial action against or terminate the QCDR as a third party intermediaries).
The simplified form is available only for existing QCDRs in good standing.
The list of vendors that have been approved to submit data to CMS as a Qualified Registry for
the 2020 performance period of MIPS will be posted in the Resource Library of the CMS Quality
Payment Program website.

CY 2021 Proposed
Rule text:
Section Header - Tips for successful self-nomination:
1. You must provide all required information at the time of self-nomination, and before the close
of the self-nomination period via the CMS Quality Payment Program portal
(https://qpp.cms.gov/login) for CMS consideration.
2. Self-nomination is an annual process. If you want to qualify as a Qualified Registry for a given
MIPS performance period, you will need to self-nominate for that MIPS performance period.
Qualification and participation in a prior program year does not automatically qualify a vendor
for subsequent MIPS performance periods.
A simplified self-nomination form is available to reduce the burden of self-nomination for those
existing Qualified Registries that have previously participated in MIPS and are in good standing
(CMS did not take remedial action against or terminate the Qualified Registry as a third party
intermediary). Please note that the simplified self-nomination form must be successfully
submitted during the self-nomination period to be considered for the given MIPS
performance period.
A simplified self-nomination form is available only to existing Qualified Registries who are in
good standing. Existing Qualified Registries in good standing should contact the MIPS
QCDR/Registry Support Team (PIMMS Team) at [email protected] if they
cannot find or access the simplified self-nomination form instead of submitting a new self
nomination form.
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Change #5:
Location: Page 2-4
Reason for Change:
Edited for alignment with finalized requirements, Edited for
clarity
CY 2020 Final Rule text:
Section Header - What are the requirements to become a Qualified
Registry?
1. Participants: You must have at least 25 participants by January 1 of the year prior to the
applicable performance period (January 1, 2019). These participants are not required to
use the Qualified Registry to report MIPS data to CMS, but they must submit data to the
Qualified Registry for quality improvement. Please note that your system must be
implemented and able to accept data from a clinician, group, or virtual group should they
wish to submit data on MIPS Quality Measures starting on January 1, 2020.
2. Certification Statement: During the data submission period, you must certify that data
submissions are true, accurate, and complete to the best of your knowledge. This
certification includes the acceptance of data exports directly from an EHR or other data
sources. If you become aware that any submitted information is not true, accurate, and
complete, you will correct such issues promptly prior to submission, and understand that

the knowing omission, misrepresentation, or falsification of any submitted information may
be punished by criminal, civil, or administrative penalties, including fines, civil damages,
and/or imprisonment.

3. Data Submission: You must submit data via a CMS-specified secure method for data
submission, such as a defined Quality Payment Program data format. Additional
information regarding data submission methodologies can be found in the Developer
Tools section of the Resource Section of the Quality Payment Program website:
https://qpp.cms.gov/developers.
4. Data Validation Plan: During self-nomination, you must thoroughly explain your process
for validation of data submitted on behalf of individual MIPS eligible clinicians, groups, and
virtual groups through the development of a Data Validation Plan. You are required to
provide the following as a part of your Data Validation Plan:
Name of Qualified Registry
Process of verifying Quality Payment Program eligibility of MIPS eligible clinicians,
groups, and virtual groups.
Process of verifying accuracy of TIN/NPIs.
Process of calculating reporting and performance rates.
Process of verifying that your system will only accept data (for purposes of MIPS) on
2020 MIPS Clinical Quality Measures and/or electronic Clinical Quality Measures during
submission.
Process used for completion of randomized audit.
Process used for completion of detailed audit.
Your Data Validation Plan will be reviewed by CMS as a part of your self-nomination
application and will need CMS approval prior to its implementation for the performance
period.
5. Data Validation Execution Report: You must execute your 2020 Data Validation Plan
and provide us with the results (i.e., Results of the randomized/detailed audits? Were
there any calculation issues? If so, why did they occur and what was done to
remediate?). Execution of your Data Validation Plan must be completed prior to the
2020 performance period data submission period, so errors can be corrected prior
to data submission.
The 2020 Data Validation Execution Report that includes the results of your audit, must
be submitted to CMS by May 31, 2021.
The following items should be addressed in the 2020 Data Validation Execution Report:
o
o

o

Name of Qualified Registry
Results of verifying MIPS eligibility of clinicians, groups, and virtual groups (i.e.
were any issues identified when determining if clinicians, groups, and virtual
groups meet the MIPS eligibility requirements? If so, please provide details and
examples regarding the identified issues and how they were resolved.)
Results of verifying the accuracy of Taxpayer Identification Number
(TIN)/National Provider Identifier (NPI) (i.e. were any issues identified when

o

o

o
o

verifying TINs/NPIs? If so, please provide details and examples regarding the
identified issues and how they were resolved).
Results of verifying that 2020 MIPS Quality Measure specifications are utilized
for submission (i.e. were any issues identified when verifying that only 2020
MIPS Quality Measures were submitted? If so, please provide details and
examples regarding the identified issues and how they were resolved).
Results of calculating data completeness and performance rates (i.e. were any
issues identified with how the MIPS quality measure specifications were
implemented in the system? If so, please provide details and examples regarding
the identified issues and how they were resolved).
Results of the randomized audit (i.e. were there any data issues identified? If so,
please provide details and examples regarding the identified issues).
Results of the detailed audit (i.e., provide details and examples regarding how
the identified data issues were resolved (Note: The detailed audit is required if
errors are found through the randomized audit).

We require Qualified Registries to utilize auditing processes to ensure the accuracy of all
data submissions under all performance categories. Qualified Registries would have
certified, at the time of submission, that the data submitted for all performance
categories is true, accurate, and complete to the best of their knowledge.
Please note, a late submission of your Data Validation Execution Report from your
Qualified Registry will be seen as non-compliance with program requirements, and may
result in remedial action or termination of the Qualified Registry in future program years.
Please note: CMS will provide a sample Data Validation Execution Report template,
which will be posted on the CMS Quality Payment Program Resource Library.
6. Performance Category Feedback Reports: Qualified Registries are required to provide
performance categories feedback at least four times a year to all individual MIPS eligible
clinicians, groups and virtual groups they are reporting for. Please note:
CMS does not provide a template for the performance feedback reports.
If a real-time feedback dashboard is available to clinicians, CMS asks that the Qualified
Registry e-mail clinicians, groups and virtual groups, at least four times a year, to remind
them the feedback is available.
CY 2021 Proposed
Rule text:
Section Header - What are the requirements to become a Qualified
Registry?
1. Participants: You must have at least 25 participants by January 1 of the year prior to the
applicable performance period (January 1, 2020 for consideration for the 2021 MIPS
performance period). These participants are not required to use the Qualified Registry to
report MIPS data to CMS, but they must submit data to the Qualified Registry for quality
improvement. Please note that your system must be implemented and able to accept
data from a clinician, group, or virtual group should they wish to submit data under
any performance category starting on January 1, 2021. A system that is not “live”
beginning with the start of the performance period is considered non-compliant with this
requirement.

2. Certification Statement: During the data submission period, you must certify that data
submissions are true, accurate, and complete to the best of your knowledge. This
certification includes the acceptance of data exports directly from an EHR or other data
sources. If you become aware that any submitted information is not true, accurate, and
complete, you will correct such issues promptly prior to submission, or refrain from
submitting it, and understand that the knowing omission, misrepresentation, or falsification
of any submitted information may be punished by criminal, civil, or administrative
penalties, including fines, civil damages, and/or imprisonment.
3. Data Submission: You must submit data via a CMS-specified secure method for data
submission, such as a defined Quality Payment Program data format. Additional
information regarding data submission methodologies can be found in the Developer
Tools section of the Resource Section of the Quality Payment Program website:
https://qpp.cms.gov/developers.
4. Data Validation Plan (DVP): During self-nomination, you must thoroughly explain your
process for validation of data submitted on behalf of individual MIPS clinicians, groups,
and virtual groups through the development of a Data Validation Plan. Execution of your
Data Validation Plan must be completed prior to data submission for the 2021
performance period for all performance categories supported, so errors can be
corrected prior to submitting. All data that is eligible to be submitted for purposes of the
MIPS program should be subject to validation, regardless of whether the clinician or group
are MIPS eligible, voluntary, or are opting in. You are required to provide the following as a
part of your Data Validation Plan:
Process of verifying Quality Payment Program eligibility of clinicians, groups, and virtual
groups. Qualified Registries are required to identify and track their clinicians as MIPS
eligible, opt-in, or voluntary reporters.
Process of verifying accuracy of tax identification number (TINs)-National Provider
Identifier (NPIs).
Process of calculating reporting and performance rates.
Process of verifying that your system will only accept data (for purposes of MIPS) on
the 2021 version of measures and activities during submission.
2021 MIPS Clinical Quality Measures (CQMs) and/or electronic Clinical Quality
Measures (eCQMs) for the Quality performance categories.
o 2021 Promoting Interoperability measures and objectives for the Promoting
Interoperability performance categories.
o 2021 Improvement Activities for the Improvement Activities performance
categories
Process used for completion of randomized audit across the Quality, Promoting
Interoperability, and/or Improvement Activities performance categories. At a minimum
must meet the following sampling methodology to meet participation requirements:
Sample 3% of the TIN/NPIs submitted to CMS, with a minimum of 10 TIN/NPIs or a
maximum sample of 50 TIN/NPIs. At least 25% of the TIN/NPI’s patients (with a minimum
sample of 5 patients or a maximum sample of 50 patients) should be reviewed for all
measures applicable to the patient).
Process used for completion of detailed audit for the Quality, Promoting Interoperability,
and/or Improvement Activities performance categories. The Detailed Audit should include
a description of the root cause analysis, how the error was corrected, and the percentage
o

of your total clinicians impacted by the data error. Please note that the sample used for
auditing in the Detailed Audit should be broadly selected, and should not only include
clinicians and groups impacted by the error in question. The aspect of the audit that is
considered “the detail” is the specific error you are auditing for. (Note: The detailed audit is
required if any errors are found through the randomized audit).
Your Data Validation Plan will be reviewed by CMS as a part of your self-nomination
application, and will need CMS approval prior to its implementation for the performance
period. Data Validation Plans cannot be changed by the Qualified Registry once it is
approved as a part of the self-nomination review.
5. Data Validation Execution Report (DVER): You must execute your 2021 Data
Validation Plan and provide us with the results (i.e., Results of the randomized/detailed
audits, identifying calculation issues, why they occurred and what was done to
remediate). Execution of your Data Validation Plan, including the identification and
correction of those errors must be completed prior to the submission of data for the
2021 MIPS performance period, for all performance categories supported.
The 2021 Data Validation Execution Report that includes the results of your audit, must be
submitted to CMS by May 31, 2022.
The following items should be addressed in the 2021 Data Validation Execution Report:
o
o
o

o

o
o

Name of Qualified Registry
Was data submitted for any of the performance categories for the 2021 MIPS
performance period?
Overall Data Error Rate - (Number of Clinicians with a Data Issue / Total Number of
clinicians Supported)
 The overall data error rate includes only data errors that were not corrected before
submission to CMS.
Results of verifying MIPS eligibility of clinicians, groups, and virtual groups (i.e. were any
issues identified when determining if clinicians, groups, and virtual groups meet the
MIPS eligibility requirements? If so, please provide details and examples regarding the
identified issues and how they were resolved.)
Results of verifying the accuracy of TIN-NPI (i.e. were any issues identified when
verifying TINs-NPIs? If so, please provide details and examples regarding the identified
issues and how they were resolved).
Results of verifying that 2021 MIPS measures and activities were utilized for submission
(i.e. were any issues identified? If so, please provide details and examples regarding the
identified issues and how they were resolved).




2021 MIPS Clinical Quality Measures (CQMs) and/or electronic
Clinical Quality Measures (eCQMs) for the Quality performance
categories.
2021 Promoting Interoperability measures and objectives for the
Quality performance categories.
2021 Improvement Activities for the Improvement Activities
performance categories

o

o
o

Results of calculating data completeness and performance rates (i.e. were any issues
identified with how the MIPS quality measure specifications were implemented in the
system? If so, please provide details and examples regarding the identified issues and
how they were resolved).
Results of the randomized audit for the Quality, Promoting Interoperability, and/or
Improvement Activities performance categories (i.e. were there any data issues
identified? If so, please provide details and examples regarding the identified issues).
Results of the detailed audit for the Quality, Promoting Interoperability, and/or
Improvement Activities performance categories (i.e., provide details and examples
regarding how the identified data issues were resolved (Note: The detailed audit is
required if any errors are found through the randomized audit). The Detailed Audit
should include a description of the root cause analysis, how the error was corrected, and
the percentage of your total clinicians impacted by the data error. Please note that the
sample used for auditing in the Detailed Audit should be broadly selected, and should
not only include clinicians and groups impacted by the error in question. The aspect of
the audit that is considered “the detail” is the specific error you are auditing for.

We require Qualified Registries to utilize auditing processes to ensure the accuracy of all data
submissions under all performance categories as Qualified Registries must be able to submit
data for all performance categories; however, a third-party intermediary may be excepted from
this requirement if all supported MIPS eligible clinicians, groups or virtual groups fall under the
reweighting policies at §414.1380(c)(2)(i)(A)(4) or (5) or §414.1380(c)(2)(i)(C)(1) through (7) or
§414.1380(c)(2)(i)(C)(9)). In instances where some of the Qualified Registry’s participants do
not fall under the reweighting policies described above, the Qualified Registry will be expected
to comply with the requirements.
Qualified Registries will certify, at the time of self-nomination, that the data submitted for all
performance categories is true, accurate, and complete to the best of their knowledge. This
certification includes the acceptance of data exports directly from an EHR or other data sources. If
you become aware that any submitted information is not true, accurate, and complete, you will
correct such issues promptly prior to submission, or refrain from submitting it, and understand that
the knowing omission, misrepresentation, or falsification of any submitted information may be
punished by criminal, civil, or administrative penalties, including fines, civil damages, and/or
imprisonment.
Please note, a late, incomplete, and/or absent submission of your Data Validation Execution
Report from your Qualified Registry will be seen as non-compliance with program requirements,
and may result in remedial action or termination of the Qualified Registry for the current and
possibly future program years of the MIPS program.
Please note: CMS will provide a sample Data Validation Execution Report template, which
will be posted on the CMS Quality Payment Program Resource Library.
6. Performance Category Feedback Reports: Qualified Registries are required to provide
performance categories feedback at least four times a year, and provide specific feedback
to all individual MIPS clinicians, groups and virtual groups on how they compare to other
clinicians who have submitted data on a given measure for all individual MIPS clinicians,
groups and virtual groups. Please note:
 CMS does not provide a template for the performance feedback reports.

 If a real-time feedback dashboard is available to clinicians, CMS asks that the Qualified
Registry e-mail clinicians, groups and virtual groups, at least four times a year, to remind
them the feedback is available.
 Exceptions to this requirement may occur if the Qualified Registry does not receive the
data from their clinician until the end of the performance period, as discussed at
§414.1400(c)(2)(ii).
7. Attest that you understand the Qualified Registry qualification criteria and program
requirements, and will meet all program requirements (such as provide performance
feedback at least 4 times a year, and provide specific feedback to clinicians and groups
on how they compare to other clinicians who have submitted data on a given measure).
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Change #6:
Location: Page 5,6
Reason for Change:
Edited for
clarity CY 2020 Final
Rule text:
Section Header - What information is required to self-nominate?
You must provide the following when you self-nominate:
 What is your Qualified Registry’s Vendor Name?
 Are you a new or existing Qualified Registry (approved in a previous year of MIPS and/or
Physician Quality Reporting System [PQRS])?
 Are you supporting MIPS Clinical Quality Measures? Please note that the MIPS clinical
quality measure must be used as specified. Measure specification changes are not permitted.
 Are you supporting MIPS electronic Clinical Quality Measures (eCQMs)? Please note that
the MIPS eCQM must be used as specified. Measure specification changes are not permitted.
 Which MIPS performance categories do you intend to support? Please note Qualified
Registries are required to support the Quality performance category.
 Which Improvement Activities are you supporting?
 Are you supporting the Promoting Interoperability Objectives and Measures set?
 Which data collection method(s) do you intend to support?
 Data Validation Plan
 Confirm you will provide your 2020 performance period Data Validation Plan results by May
31, 2021 (the Data Validation Execution Report)
 Which reporting options do you intend to support (i.e., Individual MIPS eligible clinician,
Group, Virtual Groups)?
 Specify the Cost (frequency (monthly, annual, per submission) and if the Cost is per
provider/practice) and Services Included in Cost

CY 2021 Proposed
Rule text:
Section Header - What information is required to self-nominate?
You must provide the following when you self-nominate:
 What is your Qualified Registry’s Name?
 Are you a new or existing Qualified Registry (approved in a previous year of MIPS and/or
Physician Quality Reporting System [PQRS])?
 Which MIPS performance categories do you intend to support? Please note Qualified
Registries are required to support the Quality, Promoting Interoperability, and Improvement
Activity performance categories. Third party intermediaries could be excepted from this
requirement if ALL of its supported MIPS eligible clinicians, groups or virtual groups fall under
the reweighting policies.
 Are you supporting MIPS CQMs? Please note that the reporting of MIPS CQMs must utilize
the current measure specification for the performance period in which they will be used and
must be used as specified. Third party intermediaries are not permitted to alter or
modify measure specifications.
 Are you supporting MIPS eCQMs? Please note that the reporting
of MIPS eCQMs must utilize the current measure specification for the performance period in
which they will be used and must be used as specified. Third party intermediaries are not
permitted to alter or modify measure specifications.
 Which 2021 Improvement Activities are you supporting?
 Which 2021 Promoting Interoperability Objectives and Measures are you supporting?
 Please identify your vendor type (i.e., Collaborative, Health Information Exchange/Regional
Health Information Organization, Health IT vendor, Regional Health Collaborative, Specialty
Society, Other)
 Which data collection method(s) do you utilize (i.e., claims, EHR, practice management
system, web-based tool, etc.)?
 Provide details of your Data Validation Plan (as described above).
 Confirm you will provide your 2021 performance period Data Validation Plan results by the
deadline of May 31, 2022 (the Data Validation Execution Report)
 Which reporting options do you intend to support (i.e., Individual MIPS eligible clinician,
Group, Virtual Groups, APM Entity)?
 Specify the Cost (frequency (monthly, annual, per submission) and if the Cost is per
provider/practice) and Services Included in Cost
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Change #7:
Location: Page 7,8
Reason for Change:
Edited for
clarity CY 2020 Final
Rule text:
Section Header – What data submission functions must a Qualified Registry perform?

Following the self-nomination process, an approved Qualified Registry must perform the
following data submission functions:
1. Indicate:
 Whether the Qualified Registry is using CEHRT data source
 End-to-end electronic reporting, if applicable.
 Performance period start and end dates.
 Report data on Promoting Interoperability objectives and measures or Improvement
Activities, as applicable, to the standards and requirements of the respective
performance categories.
2. Submit:
 The data and results for all supported MIPS performance categories.
 The data must include all-payer data, and not just Medicare Part B patients, as
applicable.
 Results for at least six MIPS Quality Measures (claims, MIPS CQMs, eCQMs), including
one outcome measure, as applicable.
 If an outcome measure is not available, use at least one other high-priority measure.
 Appropriate measure and activity IDs for Quality Measures, Promoting Interoperability
measures and objectives, and Improvement Activities.
 Measure-level data completeness rates by TIN/NPI and/or TIN.
 Measure-level performance rates by TIN/NPI and/or TIN.
 Risk-adjusted results for any risk-adjusted measures.
 The sampling methodology used for data validation.
3. Report on the number of:
 Eligible instances (the eligible patient population).
 Instances a quality service is performed (performance numerator).
 Instances the applicable quality action was not met (performance not met).
 Instances a performance exception/exclusion occurred (denominator exceptions/numerator
exclusions).
4. Verify and maintain eligible clinician information:
 Signed verification of clinician names, contact information, costs charged to clinicians,
services provided, MIPS Clinical Quality Measures or specialty-specific measure sets (if
applicable).
 Business associate agreement(s) with clinicians, groups or virtual groups who provide
patient-specific data.
 A practice administrator may give consent on behalf of a group or virtual group
reporting as a group, but not for an individual MIPS eligible clinician reporting as an
individual.
 Business associate agreements must comply with HIPAA Privacy and Security
Rules.
 Include disclosure of MIPS quality measure results and data on Medicare and nonMedicare beneficiaries.
 Signed NPI-holder authorization to:
 Submit results and data to CMS for MIPS.
 Certification statement that all data and results submitted to CMS are true, accurate
and complete to the best of your knowledge.
5. Comply with:
 Any CMS request to review your submitted data.
 Requirement to participate in the mandatory Qualified Registry kick-off meeting and

monthly support calls.
 Participation requirements (Data Validation Execution Report, performance feedback to
eligible clinicians, registry must be up and running by January 1 of the given performance
period, etc.).
 CMS-approved secure method for data submission
CY 2021 Proposed
Rule text:
Section Header – What are the measure specification requirements?
Following the self-nomination process, an approved Qualified Registry must perform the
following data submission functions:
1. Indicate:
 Whether the Qualified Registry is using CEHRT data source
 End-to-end electronic reporting, if applicable.
 Performance period start and end dates.
 Report data on Quality measures, Promoting Interoperability objectives and measures or
Improvement Activities, as applicable, to the standards and requirements of the respective
performance categories.
2. Submit:
 The data and results for all supported MIPS performance categories.
 The data must include all-payer data, and not just Medicare Part B patients
 Results for at least six MIPS Quality Measures (MIPS CQMs, eCQMs), including one
outcome measure, as applicable.
 If an outcome measure is not available, use at least one other high-priority
measure.
 Appropriate measure and activity IDs for Quality Measures, Promoting Interoperability
measures and objectives, and Improvement Activities.
 Measure-level data completeness rates by TIN-NPI and/or TIN.
 Measure-level performance rates by TIN-NPI and/or TIN.
 Risk-adjusted results for any risk-adjusted measures.
 The sampling methodology used for data validation.
3. Report on the number of:
 Eligible instances (eligible patient population).
 Instances a quality service is performed (performance numerator).
 Instances the applicable quality action was not met (performance not met).
 Instances a performance exception/exclusion occurred (denominator
exceptions/numerator exclusions).
4. Verify and maintain eligible clinician information:
 Signed verification of clinician names, contact information, costs charged to clinicians,
services provided, MIPS Quality Measures or specialty-specific measure sets (if
applicable).
 Business associate agreements must comply with HIPAA Privacy and Security Rules.
 Business associate agreement(s) with clinicians, groups or virtual groups who provide
patient-specific data.
 Obtain and keep on file signed documentation that each holder of an NPI whose data
are submitted to the Qualified Registry, has authorized the Qualified Registry to submit

quality measure results, improvement activities measure and activity results,
promoting interoperability results and numerator and denominator data or patient-specific
data on Medicare and non-Medicare beneficiaries to CMS for the purpose of MIPS
participation. This documentation should be obtained at the time the MIPS eligible
clinician or group signs up with the Qualified Registry to submit MIPS data to the
Qualified Registry and must meet the requirements of any applicable laws, regulations,
and contractual business associate agreements. Groups participating in MIPS via a
Qualified Registry may have their group’s duly authorized representative grant
permission to the Qualified Registry to submit their data to us. If submitting as a group,
each individual MIPS eligible clinician does not need to grant their individual permission
to the Qualified Registry to submit their data to us.
 A practice administrator may give consent on behalf of a group or virtual group
reporting as a group, but not for an individual MIPS eligible clinician reporting as an
individual. If you are submitting the individual MIPS-eligible clinician data as
an individual, you must have a business associate agreement and consent in place for
each individual clinician.
 Include disclosure of MIPS quality measure results and data on Medicare and nonMedicare beneficiaries.
 Clinician consent with signed authorization to submit results and data to CMS for
MIPS.
 Certification statement that all data and results submitted to CMS are true,
accurate, and complete to the best of your knowledge.
5. Comply with:
 Any CMS request to review your submitted data. For the purposes of auditing, CMS
may request any records or data retained for the purposes of MIPS for up to 6 years
from the end of the MIPS performance period.
 Requirement to participate in the mandatory Qualified Registry kickoff meeting and
monthly support calls.
 Participation requirements (for example, and not limited to: Data Validation Execution
Report, performance feedback to eligible clinicians, registry must be up and running by
January 1 of the given performance period, etc.).
 CMS-approved secure method for data submission.
*****
Change #8:
Location: Page 8,9
Reason for Change:
Edited for alignment with finalized requirements, Edited for clarity
2020 Final Rule text:
Section Header – What are the thresholds for data inaccuracies? What are considered data
inaccuracies?
Data inaccuracies that affect MIPS eligible clinicians, may result in:
• Remedial action may be taken against your Qualified Registry due to the low data quality
rating.

• Will have the Qualified Registry posting updated for the performance period of MIPS to
indicate the Qualified Registry’s data error rate on the CMS website until the data error
rate falls below 3 percent and that remedial action has been taken against the Qualified
Registry.
Data inaccuracies affecting more than 5% of your total MIPS eligible clinicians may lead to
termination of the Qualified Registry for future program years.
CMS will evaluate each quality measure for data completeness and accuracy. The vendor will
also attest that the data (quality measures, improvement activities, and promoting
interoperability objectives and measures) results submitted are true, accurate, and complete to
the best of their knowledge.
CMS will determine error rates calculated on data submitted to CMS for MIPS eligible clinicians.
CMS will evaluate data inaccuracies including, but not limited to:
• TIN/NPI Issues – Incorrect Tax Identification Numbers (TINs), Incorrect National Provider
Identifiers (NPIs), Submission of Group NPIs.
• Formatting Issues – Submitting files with incorrect file formats, Submitting files with
incorrect element formats, Failure to update and resubmit rejected files.
• Calculation Issues – Incorrect qualities for measure elements, performance rates, and/or
data completeness rates; numerators larger than denominators.
• Data Audit Discrepancies – Since data audits are required to occur prior to data
submission, Qualified Registries should correct all identified errors prior to submitting the
data to CMS. Qualified Registry acknowledgement of data discrepancies found post
submission from clinician feedback reports.
2021 Final Rule text:
Section Header – What are the thresholds for data inaccuracies? What are considered data
inaccuracies?
Data inaccuracies that affect MIPS clinicians, may result in:
•
•

Remedial action, up to and including termination, may be taken against your Qualified
Registry due to the low data quality rating.
The Qualified Registry posting updated for the performance period of MIPS to
indicate the Qualified Registry’s data error rate on the CMS website until the data error
rate falls below 3 percent and that remedial action or termination has been taken against
the Qualified Registry.

CMS will further evaluate the Qualified Registry to determine if any inaccurate, unusable or
otherwise compromised data affects MIPS eligible clinicians. Data inaccuracies affecting your
total MIPS eligible clinicians may lead to remedial action/termination
of the Qualified Registry for future program year(s) based on CMS discretion.
CMS will evaluate each quality measure for data completeness and accuracy. The vendor will
also attest that the data (quality measures, improvement activities,

and promoting interoperability objectives and measures) results submitted are true,
accurate, and complete to the best of their knowledge.
CMS will determine error rates calculated on data submitted to CMS for MIPS eligible
clinicians.
CMS will evaluate data inaccuracies including, but not limited to:
•
•
•
•

TIN/NPI Issues – Incorrect TINs, Incorrect NPIs, Submission of Group NPIs.
Formatting Issues – Submitting files with incorrect file formats, Submitting files with
incorrect element formats, Failure to update and resubmit rejected files.
Calculation Issues – Incorrect qualities for measure elements, performance
rates, and/or data completeness rates; numerators larger than denominators.
Data Audit Discrepancies – Since data audits are required to occur prior to data
submission, Qualified Registries should correct all identified errors prior to submitting the
data to CMS. Qualified Registry acknowledgement of data discrepancies found post
submission from clinician feedback reports.

*****
Change #9:
Location: Page 9,10
Reason for Change:
Edited for alignment with finalized requirements, Edited for clarity
2020 Final Rule text:
Section Header – What may cause remedial action to be taken or termination of third-party
intermediaries from the program?
CMS may take remedial action for failing to meet applicable criteria for approval or submit data
that is inaccurate, unusable, or otherwise compromised. Failure to comply with the remedial
action process may lead to termination of third-party intermediaries for the current and/or
subsequent performance year.
The Qualified Registry Qualified Posting will be updated to reflect when remedial action has
been taken and/or termination of third-party intermediaries participating as a Qualified Registry.
2021 Final Rule text:
Section Header – What may cause remedial action to be taken or termination of third-party
intermediaries from the program?
The CY 2020 Physician Fee Schedule (PFS) Final Rule for Quality Payment Program (84
FR §414.1400(f)) provides CMS the ability to enforce remedial action or termination based on
its determination that a third-party intermediary is non-compliant with any applicable criteria or if
the third-party intermediary submits data that is inaccurate, unusable, or otherwise
compromised.
Qualified Registries that have remedial action taken against them will be required to submit a
corrective action plan (CAP) to address any deficiencies and detail any steps taken to prevent

the deficiencies from reoccurring within a specified time period. The CAP must include the
following:
• The issues that contributed to the non-compliance.
• The impact to the individual clinicians, groups and virtual groups.
• The corrective action implemented by the Qualified Registry to ensure that the noncompliance issues have been resolved and will not be repeated in the future.
• The timeline from the issue identification to resolution.
• The resolution follow-up plan to communicate the final resolution and plan to monitor for
future issues.
Failure to comply with the remedial action process may lead to termination of third-party
intermediaries for the current and/or subsequent performance year.
The Qualified Registry Qualified Posting will be updated to reflect when remedial action has
been taken and/or termination of third-party intermediaries participating as a Qualified Registry.
*****
Change #10
Location: Page 10,11
Reason for Change:
Edited for alignment with finalized requirements, Edited for clarity
CY 2020 Final Rule Text:
Section Header - What is the overall process to become a CMS-approved Qualified Registry?
The overall process includes these steps:
• The Qualified Registry completes and submits the self-nomination form, supported MIPS
Quality Measures, and Data Validation Plan through the Quality Payment Program portal
for CMS consideration.
• If the self-nomination form, MIPS Quality Measures, and Data Validation Plan are
approved, a Qualified Posting is developed for the Qualified Registry that includes
organization type, specialty, previous participation in MIPS (if applicable), program
status (remedial action taken against the Qualified Registry or terminated as a third party
intermediary (if applicable)), contact information, last date to accept new clients, virtual
groups specialty parameters (if applicable), approved MIPS Quality Measures,
performance categories supported, services offered, and costs incurred by clients. All
approved Qualified Registries are included in the Qualified Posting that is posted on the
CMS Quality Payment Program Resource Library.
• Approved Qualified Registries are required to support the performance categories and,
measures and activities listed on their Qualified Posting and meet all applicable approval
criteria for the applicable performance period as a condition of participation in MIPS.
Failure to do so may lead to remedial action or possible termination of the Qualified
Registry from future years of MIPS.
CY 2021 Final Rule text:
Section Header- What is the overall process to become a CMS-approved Qualified Registry?
The list of CMS-approved Qualified Registries that have been approved to submit data to CMS
as a Qualified Registry for the 2021 MIPS performance period will be posted in the 2021

Qualified Registry Qualified Posting on the QPP Resource Library of the CMS Quality Payment
Program website.
The overall process includes these steps:
• The Qualified Registry completes and submits the self-nomination form, supported MIPS
Quality Measures, and Data Validation Plan through the Quality Payment Program
portal for CMS consideration.
• If the self-nomination form, MIPS Quality Measures, and Data Validation Plan are
approved, a Qualified Posting is developed for the Qualified Registry that
includes organization type, specialty, previous participation in MIPS (if
applicable), program status (remedial action taken against the Qualified Registry or
terminated as a third party intermediary (if applicable)), contact information, last date to
accept new clients, virtual groups specialty parameters (if applicable), approved MIPS
Quality Measures, reporting options supported, performance categories supported,
services offered, and costs incurred by clients. All approved Qualified Registries are
included in the Qualified Posting that is posted on the CMS Quality Payment
Program Resource Library.
• Approved Qualified Registries are required to support the performance categories,
measures and activities listed on their Qualified Posting and meet all applicable approval
criteria for the applicable performance period as a condition of participation in
MIPS. Failure to do so may lead to remedial action or possible termination of the
Qualified Registry from future program years of MIPS. Prior to discontinuing services to
any MIPS eligible clinician, group or virtual group during a performance period, the thirdparty intermediary must support the transition of such MIPS eligible clinician, group, or
virtual group to an alternate third party intermediary, submitter type, or, for any measure
on which data has been collected, collection type according to a CMS approved
transition plan.
*****
Change #11
Location: Page 11
Reason for Change:
Edited for clarity
CY 2020 Final Rule Text:
Section Header - Resources
•

•

Qualified Registry Support Calls - CMS will hold mandatory support calls for Qualified
Registries that are approved to participate in the 2020 performance period. These
support calls will be held approximately once a month, with the kick-off meeting (inperson or virtually) being the first of the monthly calls. The support calls address
reporting requirements, steps for successful submission, and allow for a question and
answer session. The monthly support calls are limited to only approved 2020
performance period Qualified Registries. Each Qualified Registry must attend both the
webinar and audio portion via computer or phone to receive credit for attending the
support call. One representative, from a vendor supporting multiple Qualified Registries,
will NOT be counted as attendance for multiple Qualified Registries.
Quality Payment Program ListServ - The Quality Payment Program ListServ will
provide news and updates on new resources, website updates, upcoming milestones,

•
•

•
•

deadlines, CMS trainings, and webinars. To subscribe, visit the Quality Payment
Program website and select “Subscribe to Updates” at the bottom of the page or in the
footer
Quality Payment Program Website - Educational documents for Qualified Registry
participation will be available on the website to help support you in your submission
process.
Quality Payment Program - If you have questions, the Quality Payment Program is
here to help and will be able to direct you to the appropriate staff to best meet your
needs. You can reach the Quality Payment Program at [email protected] or 1-866288-8292 or 1-877-715-6222 (TTY) Monday – Friday, 8:00 AM – 8:00 PM Eastern Time.
The Self-Nomination User Guide - This guide provides step-by-step instructions for
vendors looking to become a Qualified Registry for the 2020 performance period of
MIPS.
QCDR/Registry Google Calendar - Will be used to track and highlight key milestones
and activities for the annual self-nomination period.

CY 2021 Proposed Rule text:
Section Header - Resources
•

•

•

•

•

Qualified Registry Support Calls - CMS will hold mandatory joint support calls for
Qualified Registries and QCDRs that are approved to participate in
the 2021 performance period. These support calls will be held approximately once a
month, with the kick-off meeting (in-person or virtually) being the first of the monthly
calls. The support calls address reporting requirements, steps for successful submission,
and allow for a question and answer session. The monthly support calls are limited to
only approved 2021 performance period Qualified Registries. Each Qualified
Registry must attend both the webinar and audio portion via computer or phone to
receive credit for attending the support call. One representative, from a vendor
supporting multiple Qualified Registries, will NOT be counted as attendance for
multiple Qualified Registries.
Virtual Office Hours (VOHs) - CMS will host joint VOHs to offer QCDRs and Qualified
Registries an opportunity to ask CMS subject matter experts questions related to the
assigned topics for those calls. Please note that only topic specific questions will be
addressed during each call. All other questions will be referred to the Quality Payment
Program. Participation in the VOHs is not required but is strongly encouraged.
Quality Payment Program ListServ - The Quality Payment Program ListServ will
provide news and updates on new resources, website updates, upcoming milestones,
deadlines, CMS trainings, and webinars. To subscribe, visit the Quality Payment
Program website and select “Subscribe to Updates” at the bottom of the page or in the
footer.
Quality Payment Program Website - Educational documents for Qualified Registry
participation will be available on the website to help support you in your submission
process. In addition, lists with the criteria used to audit and validate data submitted in
each of the MIPS performance categories will be available on the website.
Quality Payment Program - If you have questions, the Quality Payment Program is
here to help and will be able to direct you to the appropriate staff to best meet your
needs. You can reach the Quality Payment Program at [email protected] or 1-866-

•

•

288-8292 (Monday – Friday, 8 a.m. – 8 p.m. ET). Customers who are hearing impaired
can dial 711 to be connected to a TRS Communications Assistant.
The Self-Nomination User Guide - This guide provides step-by-step instructions for
vendors looking to become a Qualified Registry for the 2021 performance period of
MIPS.
QCDR/Registry Google Calendar - Will be used to share key milestones and activities
for the annual self-nomination period.