Information Collection

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

IC 229075 under ICR 202007-0938-007 · OMB 0938-1314.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1314 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10621 Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 24)	Form
CMS-10621 Eligible Clinician and APM Entity Requests for Other Pay Appendix E1 Clinician Initiated Submission Form.pdf	Form
Appendix E2 Clinician Initiated Submission Form Crosswalk.pdf Crosswalk: Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Det	IC Document

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.1445

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10621	Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submission Form)	Appendix E1 Clinician Initiated Submission Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Quality Payment Program (QPP), System No. 09â70â 0539

FR Citation: 83 FR 6587

Number of Respondents: 150

Number of Respondents for Small Entity: 150

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	1,500	1,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk: Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submission Form)	Appendix E2 Clinician Initiated Submission Form Crosswalk.pdf	08/20/2020

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.