Crosswalk: 2020 Qualified Clinical Data Registry (QCDR) Fact Sheet

QCDR 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).
*****
Change #1:
Location: Page 1
Reason for Change:
Alignment with current year
CY 2020 Final Rule text:
Section Header2020 Qualified Clinical Data Registry (QCDR) Fact Sheet
CY 2021 Proposed Rule text:
Section Header2021 Qualified Clinical Data Registry (QCDR) Fact Sheet
*****
Change #2:
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 SelfNomination period will promptly 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 close
at 8 p.m. ET on September 1, 2020. Self-Nominations submitted after the deadline will not
be considered.
*****
Change #3:
Location: Page 1, 2
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 QCDR to report MIPS data to us; rather, they need to
submit data to the QCDR 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 QCDR 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 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.
4.

Take advantage of QCDR measure concept preview calls available until June 28th. These
collaborative preview calls include CMS, MIPS QCDR/Registry Support Team, and the
QCDR to discuss and provide feedback regarding the QCDR measure prior to selfnomination. This may also provide an opportunity to discuss current provisionally approved
QCDR measures. CMS may provide direction or suggestions to revise the QCDR measure.
Please note, decisions are not considered final during the call. To schedule a meeting,
contact the [email protected] by 5:00 pm ET on June 15, 2019. QCDR
measure concepts and specifications to be discussed at the meeting must be sent at least
one week prior to the scheduled meeting in a single Word or Excel document. If information
is not received at least one week prior to the scheduled meeting, the meeting is subject to
be rescheduled. In addition, a QCDR measure concept preview call does not qualify a
QCDR as meeting the QCDR definition for a given self-nomination period.

The list of vendors that have been approved to submit data to CMS as a QCDR 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 QCDR 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 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). 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 QCDRs who are in good
standing. Existing QCDRs 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.
3. Take advantage of QCDR measure concept preview calls available until June 30, 2020th.
These preview calls allow CMS, MIPS QCDR/Registry Support Team, and the QCDR the
opportunity to collaboratively discuss and provide feedback regarding the QCDR measure(s)
prior to self-nomination. This may also provide an opportunity to discuss current
provisionally approved QCDR measures with requested: revisions, measure harmonization,
or requests to combine measures within a single QCDR. CMS may provide preliminary input
that may be useful to revise QCDR measures. Please note, that final
measure decisions will not be made during the call. To schedule a meeting, contact the
[email protected] by 5:00 pm ET on June 12, 2020. QCDR measure
concepts and specifications to be discussed at the meeting must be sent at least one week
prior to the scheduled meeting in a single Word or Excel document. If information is not
received at least one week prior to the scheduled meeting, the meeting is subject to be
rescheduled. In addition, a QCDR measure concept preview call does not qualify a QCDR
as meeting the QCDR definition for a given self-nomination period.
*****
Change #4:
Location: Page 2, 3
Reason for Change:
Edited for alignment with finalized requirements, Edited for
clarity
CY 2020 Final Rule text:
Section Header – What is a QCDR?
A QCDR is defined as an entity that demonstrates clinical expertise in medicine and quality
measurement development that collect medical or clinical data on behalf of MIPS eligible
clinicians to track patients and diseases and foster improvement in the quality of care provided
to patients. A QCDR may include:
• An entity with clinical expertise in medicine. Clinicians must be on staff with the organization
and lend their clinical expertise in the work carried out by the organization as a QCDR.
• An entity with stand-alone quality measurement development.

• An entity that collects medical or clinical data on behalf of a MIPS eligible clinician for the
purpose of patient and disease tracking to foster improvement in the quality of care provided
to patients.
• An entity that uses an external organization for purposes of data collection, calculation, or
transmission may meet the definition of a QCDR as long as the entity has a signed, written
agreement that specifically details the relationship, roles and responsibilities of the entity with
the external organization effective as of September 1 the year prior to the year for which the
entity seeks to become a QCDR.
Entities without clinical expertise in medicine and quality measure development that want to
become a QCDR, may collaborate with entities with such expertise.
As described in the CY 2018 Quality Payment Program final rule (82 FR 53809), changes to the
QCDR’s organizational structure (for example, if a specialty society wishes to partner with a
different data submission platform vendor) are considered substantive and would need to be
updated at the time of self-nomination. The roles of each organization should be specifically
detailed within the self-nomination form.
Alternatively, entities may seek to qualify as another type of third-party intermediary, such as a
Qualified Registry. Becoming a Qualified Registry does not require the level of measure
development expertise that is needed to be a QCDR that develops measures.
The QCDR reporting option is different from a Qualified Registry because QCDRs are not
limited to reporting only MIPS Quality Measures. A QCDR may also submit a maximum of 30
QCDR measures for CMS consideration for the 2020 performance period of MIPS.
Measures submitted by a QCDR may be from one or more of the following categories:
• Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CAHPS),
which must be reported via CAHPS certified vendor. Although the CAHPS for MIPS survey is
included in the MIPS measure set, the changes needed for reporting by individual eligible
clinicians are significant enough to treat it as a QCDR measure for the purposes of reporting
via a QCDR. Please note that submitting a subset of CAHPS survey measures as a QCDR
measure will not count for credit towards completing the CAHPS for MIPS Survey.
• National Quality Forum (NQF) endorsed measures.
• Current 2020 MIPS Clinical Quality Measures.
• QCDR measures developed by boards or specialty societies with the appropriate documented
permission to the QCDR measure.
• QCDR measures developed by regional quality collaborative with the appropriate documented
permission to the QCDR measure.
CY 2021 Proposed
Rule text:
Section Header - What is a QCDR?
A QCDR is defined as an entity that demonstrates clinical expertise in medicine and quality
measurement development that collect medical or clinical data on behalf of MIPS eligible

clinicians to track patients and diseases and foster improvement in the quality of care provided
to patients. A QCDR may include:
• An entity with clinical expertise in medicine. Clinicians must be on staff with the organization
and lend their clinical expertise in the work carried out by the organization as a QCDR.
• An entity with stand-alone quality measurement development.
• An entity that collects medical or clinical data on behalf of a MIPS eligible clinician for the
purpose of patient and disease tracking to foster improvement in the quality of care provided
to patients.
• An entity that uses an external organization for purposes of data collection, calculation, or
transmission may meet the definition of a QCDR as long as the entity has a signed, written
agreement that specifically details the relationship, roles and responsibilities of the entity with
the external organization effective as of September 1 the year prior to the year for which the
entity seeks to become a QCDR.
Entities without clinical expertise in medicine and quality measure development that want to
become a QCDR, may collaborate with entities with such expertise.
As described in the CY 2018 Quality Payment Program final rule (82 FR 53809), changes to the
QCDR’s organizational structure (for example, if a specialty society wishes to partner with a
different data submission platform vendor) are considered substantive and would need to be
updated at the time of self-nomination. The roles of each organization should be specifically
detailed within the self-nomination form.
Alternatively, entities may seek to qualify as another type of third-party intermediary, such as a
Qualified Registry. Becoming a Qualified Registry does not require the level of measure
development expertise that is needed to be a QCDR that develops measures.
The QCDR reporting option is different from a Qualified Registry because QCDRs are not
limited to reporting only MIPS Quality Measures. A QCDR may also submit a maximum of 30
QCDR measures for CMS consideration for the 2021 MIPS performance period.
Measures submitted by a QCDR may be from one or more of the following categories:
• Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CAHPS),
which must be reported via CAHPS certified vendor. Although the CAHPS for MIPS survey is
included in the MIPS measure set, the changes needed for reporting by individual eligible
clinicians are significant enough to treat it as a QCDR measure for the purposes of reporting
via a QCDR. Please note that submitting a subset of CAHPS survey measures as a QCDR
measure will not count for credit towards completing the CAHPS for MIPS Survey.
• National Quality Forum (NQF) endorsed measures.
• Current 2021 MIPS Clinical Quality Measures.
• QCDR measures developed by boards or specialty societies with the appropriate documented
permission to the QCDR measure.
• QCDR measures developed by regional quality collaborative with the appropriate documented
permission to the QCDR measure.

*****
Change #5:
Location: Page 3-7
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 QCDR?
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 QCDR to report MIPS data to CMS, but they must submit data to the QCDR 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 and QCDR 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 Library 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 QCDR
 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, electronic Clinical Quality Measures and/or QCDR
measures (as applicable) 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 our 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

o

o

o
o

Name of QCDR
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 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 and/or QCDR
measure specifications are utilized for submission (i.e., were any issues identified when
verifying that only 2020 MIPS Clinical Quality Measures and/or QCDR measures (as
applicable) 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 and/or QCDR measure
specifications (as applicable) 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 QCDRs to utilize auditing processes to ensure the accuracy of all data submissions
under all performance categories. QCDRs 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 QCDR will
be seen as non-compliance with program requirements and may result in remedial action or
termination of the QCDR 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: QCDRs are required to provide performance
category feedback at least four times a year to all 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 QCDR e-mail
clinicians, groups and virtual groups at least four times a year, to remind them the feedback
is available.
CY 2021 Final Rule text:
Section Header - What are the requirements to become a QCDR?
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 QCDR to report MIPS
data to CMS, but they must submit data to the QCDR 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 Library 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. QCDRs are required to identify and track their clinicians as MIPS eligible, opt-in, or
voluntary reporters.
 Process of verifying accuracy of tax identification numbers (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
o 2021 version of measures and activities during submission
o 2021 MIPS Clinical Quality Measures (CQMs), electronic Clinical Quality Measures
(eCQMs) and/or QCDR measures 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 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.
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 our 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

Name of QCDR
Was data submitted for any of the performance categories for the 2021 MIPS
performance period?

o
o
o

o
o

o

o
o

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), electronic Clinical Quality
Measures (eCQMs) and/or QCDR measures 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
Results of calculating data completeness and performance rates (i.e., were any
issues identified with how the MIPS quality measure specifications and/or QCDR
measure specifications (as applicable) 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 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 QCDRs to utilize auditing processes to ensure the accuracy of all data submissions
under all performance categories as QCDRs 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 QCDR’s participants do not fall under
the reweighting policies described above, the QCDR will be expected to comply with the
requirements.
QCDRs 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 QCDR will be seen as non-compliance with program requirements and may
result in remedial action or termination of the QCDR 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: QCDRs are required to provide performance
category 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 QCDR email
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 QCDR 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 QCDR 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.
*****
Change #6:
Location: Page 7, 8
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 QCDR’s Vendor Name?
 Are you a new or existing QCDR (approved in a previous year of MIPS and/or Physician
Quality Reporting System [PQRS])?

 Did you submit QCDR Measure Specifications (if submitting QCDR Measures)?
 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 QCDRs are
required to support the Quality performance category.
 Which Improvement Activities are you supporting?
 Are you supporting the Promoting Interoperability Objectives and Measures set?
 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 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)
 Available Performance Data
 Risk Adjustment Method for QCDR Measures (if applicable)
 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
 Detailed information on quality measure development experience and clinical expertise
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 QCDR’s Vendor Name?
 Are you a new or existing QCDR (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 QCDRs 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 submitting a QCDR Measure Specifications (if submitting QCDR Measures)?
 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 eCQM 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)
 Available Performance Data
 Risk Adjustment Method for QCDR Measures (if applicable)
 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
 Detailed information on quality measure development experience and clinical expertise
*****
Change #7:
Location: Page 8, 9
Reason for Change:
Edited for clarity
CY 2020 Final Rule
text:
Section Header – What are the measure specification requirements?
You must provide specifications for each QCDR measure that you would like to nominate for
CMS consideration:
•

Provide QCDR measure descriptions and narrative specifications for each QCDR
measure with your submitted self-nomination application no later than the last day of the
applicable self-nomination period (September 3), utilizing the QCDR measure
submission template.

•

Publicly post the QCDR measure specifications for each QCDR measure no later than
15 calendar days following CMS’s approval of these QCDR measure specifications and
provide CMS with the link to the posted information (via a comment in your approved
self-nomination form).

QCDR Measures

MIPS Quality Measures

For QCDR Measures, QCDR measure specifications must
include:
• Measure Title and Description
• Denominator and numerator statements
• Descriptions of the denominator exceptions, denominator
exclusions, and numerator exclusions
• National Quality Strategy (NQS) domain
• Care setting
• Meaningful measure area
• Meaningful measure area rationale
• Measure type
• If the QCDR measure is a high priority measure and
priority type (if applicable)
• Data source used for the measure
• Concise summary of evidence to support performance
gap
• Performance data on the QCDR measure, average
performance rate, and number of clinicians reporting the
QCDR measure
• Measure owner, please note that permission to use
another QCDR’s measure should be obtained prior to the
QCDR measure being submitted for CMS consideration.
• National Quality Forum (NQF) number, if applicable
• Number of performance rates required for QCDR
measure
• Overall performance rate information, if more than one is
required
• Clinical recommendation statements which summarize
the clinical recommendation based on best practices
• QCDR measure rationale which provides a brief
statement describing the evidence base and/or intent for
the measure
• Traditional vs Inverse measure
• Proportional, continuous variable, ratio measure indicator
• If the QCDR measure is risk-adjusted
• Risk adjustment variables, and risk adjustment
algorithms, when applicable
• Indicate which specialty/specialties apply to the QCDR
measure
• Preferred measure clinical category
• Attestation of the feasibility of the QCDR measure at the
time of self-nomination

For MIPS Clinical Quality Measures,
only the MIPS Clinical Quality Measure
IDs for individual measures and/or the
specialty-measure set measures must
be submitted.

CY 2021 Proposed
Rule text:
Section Header – What are the measure specification requirements?
You must provide specifications for each QCDR measure that you would like to nominate for
CMS consideration:
•

•

Provide QCDR measure descriptions and narrative specifications for each QCDR
measure with your submitted self-nomination application no later than the last day of the
applicable self-nomination period (September 1, 2020), utilizing the QCDR measure
submission template.
Publicly post the QCDR measure specifications for each QCDR measure no later than
15 calendar days following CMS’s approval of these QCDR measure specifications and
provide CMS with the link to the posted information (via a comment in your approved
self-nomination form.)

QCDR Measures
For QCDR Measures, QCDR measure specifications must
include:
•
Measure Title and Description
•
QCDR measure ID for previously approved CMS measure
•
Denominator and numerator statements
•
Descriptions of the denominator exceptions, denominator
exclusions, and numerator exclusions
•
National Quality Strategy (NQS) domain
•
Care setting
•
Meaningful measure area
•
Meaningful measure area rationale
•
Measure type
•
If the QCDR measure is a high priority measure and
priority type (if applicable)
•
Primary data source used for abstraction
•
Concise summary of evidence to support performance gap
•
Performance data on the QCDR measure (number of
months collected, average performance rate, performance
range, and number of clinicians reporting the QCDR
measure)
•
Measure owner, please note that permission to use
another QCDR’s measure should be obtained prior to the
QCDR measure being submitted for CMS consideration.
•
National Quality Forum (NQF) ID number, if applicable
•
Number of performance rates required for QCDR measure
•
Overall performance rate information, if more than one is
required
•
Clinical recommendation statements which summarize the
clinical recommendation based on best practices
•
QCDR measure rationale which provides a brief statement
describing the evidence base and/or intent for the
measure
•
Traditional vs Inverse measure
•
Proportional, continuous variable, ratio measure indicator
•
If the QCDR measure is risk-adjusted and which score is
risk-adjusted
•
Risk adjustment variables, and risk adjustment algorithms,
when applicable
•
Indicate if the QCDR measure was tested at the individual
clinician level
•
Describe link to Cost measure/Improvement Activity
•
Indicate which specialty/specialties apply to the QCDR
measure
•
Preferred measure clinical category
•
Attestation of the feasibility of the QCDR measure at the
time of self-nomination

MIPS Quality Measures

For MIPS Clinical Quality
Measures, only the MIPS Clinical
Quality Measure IDs for
individual measures and/or the
specialty measure set measures
must be submitted.

*****
Change #8:
Location: Page 10-13
Reason for Change:
Edited for alignment with finalized requirements, Edited for clarity
2020 Final Rule text:
Section Header – What are the QCDR measure consideration criteria?
Prior to self-nomination of a QCDR measure, the following checklist should be reviewed to
increase the likelihood of approval of the QCDR measure. CMS and the contractor team use a
similar checklist during the review of QCDR measures.
QCDR measures should:
•
•
•
•
•
•
•
•
•
•
•
•
•

Be developed using the measure development processes as defined in the CMS
Blueprint.
Be clinically relevant and evidence based (align with current clinical guidelines).
Include evidence of a performance gap either by providing performance data or the most
recent study citation supporting a performance gap.
Address requested revisions made by CMS during the previous performance period of
MIPS (Provisionally Approved measures) or provide rationale of why the CMS request is
not clinically appropriate.
Focus on a quality action instead of documentation.
Focus on an outcome rather than a clinical process.
Have opportunity for adequate patient population and measure adoption for the QCDR
measure to have a more significant impact on quality improvement.
Clearly define the quality action and population in the description for eligible clinician
ease of understanding.
Address one or more Meaningful Measure Areas and National Quality Strategy domains.
Be fully developed and not just in the concept development phase. End to end testing or
process validation should be performed to ensure data can be collected or extracted,
received and calculations can occur.
Indicate accurate measure analytics (inverse, risk-adjusted, ratio, proportional, or
continuous variable)
Be thoroughly proofread by the QCDR to ensure proper spelling and grammar
throughout the QCDR measure specification.
Identify whether there are changes to the QCDR measure specification for the upcoming
performance period of MIPS, if approved from a previous performance period of MIPS.
Please note, substantive changes that alter the intent of the QCDR measure, and may
impact the performance score and benchmarking may result in a new measure ID being
assigned.

QCDR measures should not:
•
•

Duplicate an existing or proposed MIPS clinical quality measure (CQM/eCQM).
Duplicate an existing QCDR measure (unless the new measure is a substantial
improvement over the existing measure).

To reduce the number of duplicative QCDR measures in MIPS, CMS
encourages QCDRs to share and/or harmonize QCDR measures that are
similar in topic and/or concept.
Duplicate a retired Physician Quality Reporting System (PQRS) or quality measure.
Include measures that are considered topped out with performance rates. Topped out
non-process measures means a measure where the Truncated Coefficient of Variation is
less than 0.10 and the 75th and 90th percentiles are within 2 standard errors. Topped
out process measures mean a measure with a median performance rate of 95 percent or
higher.
Split a single or related clinical process or outcome into several QCDR measures. For
example: the results of three different tests are required for a standard of care. Each test
should not be a single measure but all three should be combined into one
comprehensive measure.
Have the potential of unintended consequences. For example, a measure that
discourages an oncology patient from receiving oxygen therapy or other comfort
measures.
Focus on the elimination of serious, preventable, and costly medical errors that are
highly unlikely to occur, so-called “Never Events”. For example: Surgery performed on
the wrong patient or a fire in the operating room.
Be overly burdensome to the MIPS eligible clinician.
Be a standard of care with the expectation it is performed consistently (low bar).
Be incidence measures - measures that count the occurrence of new or newly
diagnosed cases of a specified disease, illness, or injury within the indicated timeframe.
Have a quality action that is not attributable to the submitting eligible clinician.
Be documentation/check box measures.
o

•
•

•

•
•
•
•
•
•
•

CMS recommends that QCDRs utilize the following when developing and self-nominating
QCDR measures:
•
•
•

Measure Development Plan
QCDR Measure Development Handbook
CMS Blueprint

2021 Final Rule text:
Section Header – What are the QCDR measure consideration criteria??
QCDRs should be able to collect ALL that is required for the QCDR measure and feasibly
implement the QCDR measure by January 1 of the performance period. Prior to submitting a
QCDR measure for CMS consideration, the following checklist should be reviewed. CMS uses a
similar checklist during the QCDR measure review process. For additional information, please
reference section §414.1400(b)(3) of the Physician Fee Schedule 2020 Final Rule. QCDR
measures should:
•
•
•

Be developed using the measure development processes as defined in the most recent
Blueprint for the CMS Measures Management System.
Be clinically relevant and evidence based (align with current clinical guidelines).
Include evidence of a performance gap. CMS encourages QCDRs to collect data for 12
months prior to submission which increases the likelihood the QCDR measure could be

•
•
•
•

benchmarked. NOTE: CMS is delaying the implementation of the collection of data
requirement for QCDR measures policy by one year. Beginning with the 2022
performance period, QCDRs are required to collect data on a QCDR measure,
appropriate to the measure type, prior to submitting the QCDR measure for CMS
consideration during the self-nomination period. Please reference CMS’ most recent
release of the Interim Final Rule with Public Comment: Medicare and Medicaid IFC:
Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health
Emergency (CMS-5531 IFC).
Address requested/required revisions made by CMS during the previous performance
period of MIPS (Provisionally Approved measures) or provide rationale of why the CMS
request is not clinically appropriate.
Focus on a quality action instead of documentation.
Focus on an outcome rather than a clinical process.
Address one or more Meaningful Measure Areas and National Quality Strategy domains:
o Focus on measures that address patient safety and adverse events.
o Focus on measures that identify appropriate use of diagnosis and therapeutics.
o

•
•
•

•
•
•

•

Focus on measures that address the NQS domain of care coordination.

o

Focus on measures that address the NQS domain for patient and caregiver

o

Focus on measures that address efficiency, cost, and resource use.

experience.

Have opportunity for adequate patient population and measure adoption for the QCDR
measure to have a more significant impact on quality improvement.
Clearly define the quality action and population in the description for eligible clinician
ease of understanding.
Be fully developed and not just in the concept development phase. End to end testing or
process validation should be performed to ensure data can be collected or extracted,
received and calculations can occur.
o If a QCDR measure is being used by a QCDR that does not own the measure,
it is expected that the ability to abstract the data according to the QCDR measure
owner’s specifications is a condition of self-nominating the QCDR measure.
Withdrawing of the QCDR measure during an active performance period is not
acceptable.
Indicate accurate measure analytics (inverse, risk-adjusted, ratio, proportional, or
continuous variable).
Be thoroughly vetted by the QCDR to ensure proper spelling and grammar throughout
the QCDR measure specification.
Identify whether there are changes to the QCDR measure specification for the upcoming
performance period of MIPS, if approved from a previous performance period of MIPS.
Please note, substantive changes that alter the intent of the QCDR measure and may
impact the performance score and benchmarking will result in a new QCDR measure ID
being assigned.
Identify linkage to a cost measure and improvement activity. (In cases where a QCDR
measure does not have a clear link to a cost measure and an improvement activity, we
would consider exceptions if the potential QCDR measure otherwise meets the QCDR
measure requirements and considerations.)

QCDR measures should not:
•
•

•
•

•

•
•
•
•

•
•
•

Duplicate an existing or proposed MIPS quality measure (CQM/eCQM).
Duplicate an existing QCDR measure (unless the new measure is a substantial
improvement over the existing measure).
o To reduce the number of duplicative QCDR measures in MIPS, CMS encourages
QCDRs to share and/or harmonize QCDR measures that are similar in topic
and/or concept. CMS will likely not approve measures that are duplicative or very
similar to one another since harmonized QCDR measures allow for a larger
cohort on which clinicians can be compared. NOTE: CMS strongly encourages
QCDRs to perform an environmental scan prior to developing a QCDR measure.
Duplicate a retired Physician Quality Reporting System (PQRS) or MIPS quality
measure (CQM/eCQM).
Include measures that are considered topped out with performance rates at or near
100% (or 0% for inverse measures). Topped out measures are defined as above 95% or
less than 5% for inverse measures. This definition aligns with other CMS Value Based
Payment programs.
Split a single or related clinical process or outcome into several QCDR measures. For
example: the results of three different tests are required for a standard of care. Each test
should not be a single measure but all three should be combined into one
comprehensive measure.
Have the potential of unintended consequences. For example, a measure that
discourages an oncology patient from receiving oxygen therapy or other comfort
measures.
Focus on the elimination of serious, preventable, and costly medical errors that are
highly unlikely to occur, so-called “Never Events”. For example: Surgery performed on
the wrong patient or a fire in the operating room.
Be burdensome to the MIPS eligible clinician.
Be a standard of care with the expectation it is performed consistently (low bar). While
measures that are a standard of care represent important clinical topics, they do not
provide value to a pay for performance program. Continued data capture for purposes
outside of the MIPS program are encouraged.
Be incidence measures.
Have a quality action that is not attributed to or not completed by the submitting eligible
clinician.
Be documentation/check box measures.

Beginning with the 2021 MIPS performance period, QCDR measures may be approved for 2
years, at CMS discretion. Upon annual review, CMS may revoke QCDR measure second year
approval, if the QCDR measure is found to be: topped out; duplicative of a more robust
measure; reflects an outdated clinical guideline; requires QCDR measure harmonization; or if
the QCDR that is nominating the QCDR measure is no longer in good standing
[§414.1400(b)(3)(iv)(J)(2)(vi)].
If a QCDR measure fails to meet benchmarking thresholds for two consecutive performance
periods (data submitted is insufficient in meeting the case minimum and volume thresholds
required for benchmarking), the QCDR may submit a participation plan for CMS consideration if

the QCDR believes the QCDR measure is important and relevant to a specialist’s practice.
Please note that the submission of a participation plan does not guarantee the approval of a
QCDR measure for the upcoming performance period.
o Participation Plan: Detailed plan and methods to encourage MIPS clinicians,
groups, or virtual groups to increase QCDR measure adoption.
 As examples, a QCDR measure participation plan could include one
or more of the following: Development of an education and
communication plan; update the QCDR measure’s specification with
changes to encourage broader participation; require reporting on the
QCDR measure as a condition of reporting through the QCDR.
CMS recommends that QCDRs utilize the following when developing and self-nominating
QCDR measures:
•
•
•

Measure Development Plan
QCDR Measure Development Handbook
CMS Blueprint

*****
Change #9
Location: Page 13, 14
Reason for Change:
Edited for clarity
CY 2020 Final Rule Text:
Section Header- What data submission functions must an approved QCDR perform?
Following the self-nomination process and QCDR measure review process, an approved QCDR
must perform the following data submission functions:
1. Indicate:
 Whether the QCDR 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 Quality Measures (claims, MIPS CQMs, eCQMs, and/or QCDR
measures), including one outcome measure, as applicable.
 If an outcome measure is not available, use at least one other high-priority measure.

 Give entire distribution of measure results by decile, if available.
 Additional information about benchmarks can be found in the Quality
Benchmarks zip file.
 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.
 The sampling methodology used for data validation.
 Risk-adjusted results for any risk-adjusted measures.
 Additional details for QCDR Measures:
 Data elements and QCDR measure specifications.
 Risk-adjusted results for QCDR quality data.
 Comparison of quality of care by measure, by clinician or group.
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 QCDR kick-off meeting and monthly support
calls.

 Participation requirements (Data Validation Execution Report, performance feedback to
eligible clinicians, QCDR must be up and running by January 1 of the given performance
period, etc.).
 CMS-approved secure method for data submission.
CY 2021 Final Rule text:
Section Header- What data submission functions must an approved QCDR perform?
Following the self-nomination and QCDR measure process, an approved QCDR must perform
the following data submission functions:
1. Indicate:
 Whether the QCDR 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
and objectives 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 Quality Measures (MIPS CQMs, eCQMs, and/or QCDR
measures), including one outcome measure, as applicable.
 If an outcome measure is not available, use at least one other high priority
measure.
 Give entire distribution of measure results by decile, if available.
 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.
 The sampling methodology used for data validation.
 Risk-adjusted results for any risk-adjusted measures.
 Additional details for QCDR Measures:
 Data elements and QCDR measure specifications.
 Risk-adjusted results for QCDR quality data, if applicable.
 Comparison of quality of care by measure, by clinician or group.
3. Report on the number of:
 Eligible instances (eligible patient population).
 Instances a quality action is performed (performance met).
 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, services provided, costs
charged to clinicians, Quality Measures (MIPS Quality Measures and/or QCDR
Measures), and specialty-specific measure sets (if applicable).
 Business associate agreements must comply with HIPAA Privacy and Security Rules.
 Business 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 QCDR, has authorized the QCDR 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 QCDR to
submit MIPS data to the QCDR and must meet the requirements of any applicable laws,
regulations, and contractual business associate agreements. Groups participating in
MIPS via a QCDR may have their group’s duly authorized representative grant
permission to the QCDR 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
QCDR 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 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 QCDR kickoff meeting and monthly support
calls.
 Participation requirements (for example, and not limited to: Data Validation Execution
Report, performance feedback to eligible clinicians, QCDR must be up and running by
January 1 of the given performance period, etc.).
 A CMS-approved secure method for data submission.
*****
Change #10
Location: Page 15
Reason for Change:
Edited for alignment with finalized requirements, Edited for clarity
CY 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 QCDR due to the low data quality rating.
Will have the QCDR Qualified Posting updated for the performance period of MIPS to
indicate the QCDR’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 QCDR.

Data inaccuracies affecting more than 5% of your total MIPS eligible clinicians may lead to
termination of the QCDR for future program year(s).
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,
QCDRs should correct all identified errors prior to submitting the data to CMS. QCDR
acknowledgement of data discrepancies found post submission from clinician feedback reports.
CY 2021 Proposed 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 QCDR due
to the low data quality rating.
The QCDR Qualified Posting updated for the performance period of MIPS to indicate the
QCDR’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 QCDR.

CMS will further evaluate the QCDR 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 QCDR 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, QCDRs should correct all identified errors prior to submitting the data to
CMS. QCDR acknowledgement of data discrepancies found post submission from
clinician feedback reports.

*****
Change #11
Location: Page 15, 16
Reason for Change:
Edited for alignment with finalized requirements, Edited for clarity
CY 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 QCDR Qualified Posting will be updated to reflect when remedial action has been taken
and/or termination of third party intermediaries participating as a qualified QCDR.
CY 2021 Proposed 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.
QCDRs 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 QCDR to ensure that the non-compliance
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 QCDR Qualified Posting will be updated to reflect when remedial action has been taken
and/or termination of third-party intermediaries participating as a qualified QCDR.
*****
Change #12
Location: Page 16,17
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 an approved QCDR?
The overall process includes these steps:
•
•

•

The QCDR completes and submits the self-nomination form, supported measures (MIPS
Quality Measures and/or QCDR 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, all submitted QCDR measures are reviewed (if applicable). CMS may approve,
provisionally approve, or reject the QCDR measures. The QCDR measure statuses are
defined as:
o Approved – The QCDR measure is approved for the given performance period.
o Provisionally Approved – The QCDR measure is approved for the given
performance period however, CMS is requesting additional information or action
if the QCDR measure is resubmitted for subsequent performance periods. CMS
will provide a rationale for the provisional status. This may include performance
data to assess performance gaps, revision or harmonization of the QCDR
measure if it is to be submitted during the next self-nomination period.
o Rejected – The QCDR measure is not approved for the given performance
period. CMS will provide a rationale for the rejection.
The Qualified Posting is developed for the approved QCDRs and include organization
type, specialty, previous participation in MIPS (if applicable), program status (remedial
action taken against the QCDR or terminated as a third part intermediary (if applicable)),
contact information, last date to accept new clients, virtual groups specialty parameters (if
applicable), the approved measures, performance categories supported, services offered,

•
•

and costs incurred by clients. All approved QCDRs are included in the Qualified Posting
that is posted on the CMS Quality Payment Program Resource Library.
Approved QCDRs review and acknowledge the measure specifications for their approved
QCDR measures.
Approved QCDRs 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 QCDR from future years of
MIPS.

CY 2021 Proposed Rule text:
Section Header - What is the overall process to become an approved QCDR?
The list of CMS-approved QCDRs that have been approved to submit data to CMS as a QCDR
for the 2021 MIPS performance period will be posted in the 2021 QCDR Qualified Posting on
the QPP Resource Library of the CMS Quality Payment Program website. The overall process
includes these steps:
•
•

•

•
•

The QCDR completes and submits the self-nomination form, supported measures (MIPS
Quality Measures and/or QCDR 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, all submitted QCDR measures are reviewed (if applicable). CMS may approve,
provisionally approve, or reject the QCDR measures. The QCDR measure statuses are
defined as:
o Approved – The QCDR measure is approved for the given performance period.
o Provisionally Approved – The QCDR measure is approved for the given
performance period. However, CMS is requesting additional information or action
if the QCDR measure is resubmitted for subsequent performance periods. CMS
will provide a rationale for the provisional status. This may include performance
data to assess performance gaps, revision or harmonization of the QCDR
measure if it is to be submitted during the next self-nomination period.
o Rejected – The QCDR measure is not approved for the given performance
period. CMS will provide a rationale for the rejection.
The Qualified Posting is developed for the approved QCDRs and include organization
type, specialty, previous participation in MIPS (if applicable), program status (remedial
action taken against the QCDR or terminated as a third part intermediary (if applicable)),
contact information, last date to accept new clients, virtual groups specialty parameters (if
applicable), the approved quality measures, reporting options supported, performance
categories supported, services offered, and costs incurred by clients. All approved
QCDRs are included in the Qualified Posting that is posted on the CMS Quality Payment
Program Resource Library.
Approved QCDRs review and acknowledge the measure specifications for their approved
QCDR measures.
Approved QCDRs 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 QCDR from future program

years of MIPS. Prior to discontinuing services to any MIPS eligible clinician, group or
virtual group during a performance period, the third party 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 #13
Location: Page 17, 18
Reason for Change:
Edited for clarity
CY 2020 Final Rule Text:
Section Header- Resources
•

•

•
•

•

•

•

QCDR Support Calls - CMS will hold mandatory support calls for QCDRs 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 (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 2020 performance period QCDRs. Each
QCDR 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 QCDRs, will NOT be counted as attendance for multiple QCDRs.
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 QCDR participation
will be available on the website to help support you in your submission process.
Quality Payment Program - If you have any 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 an approved QCDR for the 2020 performance period of
MIPS.
Blueprint for the CMS Measures Management System - Provides a standardized
system for developing and maintaining the Quality Measures used in CMS’s various
quality initiatives and programs. The primary goal is to provide guidance to measure
developers to help them produce high-caliber healthcare Quality Measures and
documents the core set of business processes and decisions criteria when developing,
implementing, and maintaining measures.
Measure Development Plan - Is a focused framework to help CMS build and improve
Quality Measures that clinicians could report under MIPS and as participants in
Advanced Alternative Payment Models (collectively known as the Quality Payment
Program).

•

•

•

QCDR Measure Development Handbook - Provides guidance and suggestions to
QCDR measure developers on QCDR measure structure, analytics and types as well as
a QCDR measure development check list, resources for QCDR measure development
and definitions used by CMS to communicate QCDR measure review decisions.
QCDR Measure Development Google Group - Provides a space for QCDRs to
collaborate on QCDR measures and share ideas throughout the QCDR measure
development process.
QCDR/Registry Google Calendar - Will be used to share CMS availability for QCDR
measure reconsideration calls (after the self-nomination period ends) and to track and
highlight key milestones and activities for the annual self-nomination period.

CY 2021 Proposed Rule text:
Section Header- Resources
•

•

•

•

•

•

QCDR Support Calls - CMS will hold mandatory joint support calls for QCDRs and
Qualified Registries 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 QCDRs. Each QCDR 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 QCDRs, will NOT be counted as
attendance for multiple QCDRs.
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 QCDR 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 any 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 an approved QCDR for the 2021 performance period of
MIPS.

•

•

•

•
•

Blueprint for the CMS Measures Management System - Provides a standardized
system for developing and maintaining the Quality Measures used in CMS’s various
quality initiatives and programs. The primary goal is to provide guidance to measure
developers to help them produce high-caliber healthcare Quality Measures and
documents the core set of business processes and decisions criteria when developing,
implementing, and maintaining measures.
Measure Development Plan - Is a focused framework to help CMS build and improve
Quality Measures that clinicians could report under MIPS and as participants in
Advanced Alternative Payment Models (collectively known as the Quality Payment
Program).
QCDR Measure Development Handbook - Provides guidance and suggestions to
QCDR measure developers on QCDR measure structure, analytics and types as well as
a QCDR measure development check list, resources for QCDR measure development
and definitions used by CMS to communicate QCDR measure review decisions.
QCDR Measure Development Google Group - Provides a space for QCDRs to
collaborate on QCDR measures and share ideas throughout the QCDR measure
development process.
QCDR/Registry Google Calendar - Will be used to share key milestones and activities
for the annual self-nomination period.