Quality Payment Program/Merit-Based Incentive Payment System (MIPS) (CMS-10621)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10621 Stakeholder Submissions of MIPS Value Pathways (MVP) Candidates: Instructions and Template	Form and Instruction	New	Available
Form CMS-10621 Nomination of MVPs (SS-A Table 23)	Form and Instruction	New	Repair queued
Form CMS-10621 Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option	Form	New	Available
Form CMS-10621 Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 27)	Form	New	Repair queued
Form CMS-10621 Measures under Consideration 2019, Data Template for Candidate Measures	Form and Instruction	New	Available
Form CMS-10621 (Quality Performance Category) Call for Quality Measures (see SS-A Table 15)	Form and Instruction	New	Repair queued
Form CMS-10621 Peer Reviewed Journal Article Requirement Template	Form and Instruction	New	Available
Form CMS-10621 Eligible Clinician Initiated Submission Form	Form	New	Available
Form CMS-10621 Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 26)	Form	New	Repair queued
Form CMS-10621 Promoting Interoperability Performance Category, 2021 Call for Measures Submission Form	Form and Instruction	New	Repair queued
Form CMS-10621 (PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 19)	Form and Instruction	New	Repair queued
Form CMS-10621 Payer Initiated Submission Form	Form and Instruction	New	Repair queued
Form CMS-10621 Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 25)	Form and Instruction	New	Repair queued
Form CMS-10621 Improvement Activities Performance Category, 2021 Call for Activities Submission Form	Form	New	Available
Form CMS-10621 (Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 22)	Form	New	Repair queued
Form CMS-10621 Extreme and Uncontrollable Circumstances Application Form	Form	New	Available
Form CMS-10621 (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)	Form	New	Repair queued
Form CMS-10621 Hardship Exception Application Form	Form	New	Available
Form CMS-10621 2021 Qualified Clinical Data Registry (QCDR) Measure Submission Template	Form	New	Available
Form CMS-10621 Stakeholder Submissions of MIPS Value Pathways (MVP) Candidates: Instructions and Template	Form and Instruction	New	Repair queued
Form CMS-10621 Nomination of MVPs (SS-A Table 23)	Form and Instruction	New	Repair queued
Form CMS-10621 Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option	Form	Modified	Available
Form CMS-10621 Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 27)	Form	Modified	Repair queued
Form CMS-10621 Measures under Consideration 2019, Data Template for Candidate Measures	Form and Instruction	Modified	Available
Form CMS-10621 Peer Reviewed Journal Article Requirement Template	Form and Instruction	Modified	Available
Form CMS-10621 (Quality Performance Category) Call for Quality Measures (see SS-A Table 15)	Form and Instruction	Modified	Repair queued
Form CMS-10621 Eligible Clinician Initiated Submission Form	Form	Modified	Available
Form CMS-10621 Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 26)	Form	Modified	Repair queued
Form CMS-10621 Promoting Interoperability Performance Category, 2021 Call for Measures Submission Form	Form and Instruction	Modified	Repair queued
Form CMS-10621 (PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 19)	Form and Instruction	Modified	Repair queued
Form CMS-10621 Payer Initiated Submission Form	Form and Instruction	Modified	Available
Form CMS-10621 Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 25)	Form and Instruction	Modified	Repair queued
Form CMS-10621 Improvement Activities Performance Category, 2021 Call for Activities Submission Form	Form	Modified	Available
Form CMS-10621 (Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 22)	Form	Modified	Repair queued
Form CMS-10621 Extreme and Uncontrollable Circumstances Application Form	Form	Modified	Available
Form CMS-10621 (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)	Form	Modified	Repair queued
Form CMS-10621 Hardship Exception Application Form	Form	Modified	Available
Form CMS-10621 2021 Qualified Clinical Data Registry (QCDR) Measure Submission Template	Form	Modified	Available
CMS-10621 - Supporting Statement B (CMS-1734-P)_12012020.docx	Supporting Statement B	Uploaded 2021-03-03	Repair queued
CMS-10621 - Supporting Statement A (CMS-1734-F version 7).docx	Supporting Statement A	Uploaded 2021-03-03	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
245893	2022 >> Open Authorization Credentialing and Token Request Process (SS-A Table 5)		New
245892	2022 >> Nomination of MVPs (SS-A Table 23)	Form and Instruction	New	Stakeholder Submissions of MIPS Value Pathways (MVP) Candidates: Instructions and Template
245892	Nomination of MVPs (SS-A Table 23)	Form and Instruction	New
245891	2022 >> Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 27)	Form	New	Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option
245891	Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 27)	Form	New
245886	2022 >> QPP Identity Management Application Process (see SS-A Table 9)		New
245885	2022 >> (Quality Performance Category) Call for Quality Measures (see SS-A Table 15)	Form and Instruction	New	Measures under Consideration 2019, Data Template for Candidate Measures
245885	(Quality Performance Category) Call for Quality Measures (see SS-A Table 15)	Form and Instruction	New
245885	2022 >> (Quality Performance Category) Call for Quality Measures (see SS-A Table 15)	Form and Instruction	New	Peer Reviewed Journal Article Requirement Template
245884	2022 >> Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 26)	Form	New	Eligible Clinician Initiated Submission Form
245884	Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 26)	Form	New
245883	2022 >> (PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 19)	Form and Instruction	New	Promoting Interoperability Performance Category, 2021 Call for Measures Submission Form
245883	(PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 19)	Form and Instruction	New
245882	2022 >> (Physician Compare) Opt Out for Voluntary Participants (see SS-A Table 28)		New
245881	2022 >> Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 25)	Form and Instruction	New	Payer Initiated Submission Form
245881	Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 25)	Form and Instruction	New
245880	2022 >> (Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 22)	Form	New	Improvement Activities Performance Category, 2021 Call for Activities Submission Form
245880	(Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 22)	Form	New
245879	2022 >> (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)	Form	New	Extreme and Uncontrollable Circumstances Application Form
245879	(PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)	Form	New
245879	2022 >> (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)	Form	New	Hardship Exception Application Form
245877	2022 >> Partial Qualifying APM Participant (QP) Election (see SS-A Table 24)		New
245875	2022 >> (Improvement Activities Performance Category) Data Submission (see SS-A Table 21)		New
245874	2022 >> (PI Performance Category) Data Submission (see SS-A Table 18)		New
245873	2022 >> Self-nomination: QCDR and Qualified Registry (see SS-A Tables 3 and 4)	Form	New	2021 Qualified Clinical Data Registry (QCDR) Measure Submission Template
245873	2022 >> Self-nomination: QCDR and Qualified Registry (see SS-A Tables 3 and 4)	Instruction	New
245870	2022 >> (Quality Performance Category) eCQM Collection Type (see SS-A Table 12)		New
245869	2022 >> (Quality Performance Category) QCDR/MIPS CQM Collection Type (see SS-A Table 11)		New
245867	2022 >> (Quality Performance Category) Claims Collection Type (see Table SS-A 10)		New
245240	2021 > Open Authorization Credentialing and Token Request Process (SS-A Table 5)		New
245229	2021 > Nomination of MVPs (SS-A Table 23)	Form and Instruction	New	Stakeholder Submissions of MIPS Value Pathways (MVP) Candidates: Instructions and Template
245229	Nomination of MVPs (SS-A Table 23)	Form and Instruction	New
233582	2021 > Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 27)	Form	Modified	Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option
233582	Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 27)	Form	Modified
233581	2021 > QPP Identity Management Application Process (see SS-A Table 9)		Modified
229086	2021 > (Quality Performance Category) Call for Quality Measures (see SS-A Table 15)	Form and Instruction	Modified	Measures under Consideration 2019, Data Template for Candidate Measures
229086	2021 > (Quality Performance Category) Call for Quality Measures (see SS-A Table 15)	Form and Instruction	Modified	Peer Reviewed Journal Article Requirement Template
229086	(Quality Performance Category) Call for Quality Measures (see SS-A Table 15)	Form and Instruction	Modified
229075	2021 > Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 26)	Form	Modified	Eligible Clinician Initiated Submission Form
229075	Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 26)	Form	Modified
229074	2021 > (PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 19)	Form and Instruction	Modified	Promoting Interoperability Performance Category, 2021 Call for Measures Submission Form
229074	(PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 19)	Form and Instruction	Modified
227511	2021 > (Physician Compare) Opt Out for Voluntary Participants (see SS-A Table 28)		Modified
227509	2021 > Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 25)	Form and Instruction	Modified	Payer Initiated Submission Form
227509	Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 25)	Form and Instruction	Modified
227507	2021 > (Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 22)	Form	Modified	Improvement Activities Performance Category, 2021 Call for Activities Submission Form
227507	(Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 22)	Form	Modified
227506	2021 > (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)	Form	Modified	Extreme and Uncontrollable Circumstances Application Form
227506	(PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)	Form	Modified
227506	2021 > (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)	Form	Modified	Hardship Exception Application Form
227505	2021 > (Quality Performance Category) Registration and Enrollment for CMS Web Interface (see SS-A Table 14)	Instruction	Modified
221786	2021 > Partial Qualifying APM Participant (QP) Election (see SS-A Table 24)		Modified
221785	2021 > (Improvement Activities Performance Category) Data Submission (see SS-A Table 21)		Modified
221784	2021 > (PI Performance Category) Data Submission (see SS-A Table 18)		Modified
221782	2021 > Self-nomination: QCDR and Qualified Registry (see SS-A Tables 3 and 4)	Form	Modified	2021 Qualified Clinical Data Registry (QCDR) Measure Submission Template
221782	2021 > Self-nomination: QCDR and Qualified Registry (see SS-A Tables 3 and 4)	Instruction	Modified
221781	2021 > (Quality Performance Category) CMS Web Interface Submission Type (see SS-A Table 13)		Modified
221780	2021 > (Quality Performance Category) eCQM Collection Type (see SS-A Table 12)		Modified
221779	2021 > (Quality Performance Category) QCDR/MIPS CQM Collection Type (see SS-A Table 11)		Modified
221777	2021 > (Quality Performance Category) Claims Collection Type (see Table SS-A 10)		Modified

ICR Details

OMB Control No: 0938-1314	ICR Reference No: 202101-0938-003
Status: Historical Active	Previous ICR Reference No: 201911-0938-009
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Quality Payment Program/Merit-Based Incentive Payment System (MIPS) (CMS-10621)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/28/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/04/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2022	36 Months From Approved	01/31/2022
Responses	654,162	0	475,198
Time Burden (Hours)	2,957,004	0	2,937,891
Cost Burden (Dollars)	0	0	0

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Abstract: Section 1848(q) of the Social Security Act, as amended by section 101 of the Medicare Access and CHIP Reauthorization Act of 2015, authorizes the establishment of a Merit-based Incentive Payment System (MIPS) for eligible clinicians. Beginning in CY 2017, eligible clinicians are required to collect and submit data on four performance categories to CMS (quality, cost, advancing care information and improvement activities). This program replaces and consolidates portions of the PQRS, Value-based Modifier, and the Medicare EHR Incentive Program. The Act also establishes a second track, Advanced Alternative Payment Models (APMs) for clinicians to participate in instead of MIPS.

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Authorizing Statute(s): US Code: 42 USC 1395w-4 Name of Law: Medicare Access and CHIP Reauthorization Act of 2014
  

Citations for New Statutory Requirements: US Code: 42 USC 1395w-4 Name of Law: Medicare Access and CHIP Reauthorization Act of 2014

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AU10	Final or interim final rulemaking	85 FR 84472	12/28/2020

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 50074	08/17/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 84472	12/28/2020
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 38

table that charts list of burden

IC Title	Form No.	Form Name
2021 > (Improvement Activities Performance Category) Data Submission (see SS-A Table 21)
2021 > (Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 22)	CMS-10621	Improvement Activities Performance Category, 2021 Call for Activities Submission Form
2021 > (PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 19)	CMS-10621	Promoting Interoperability Performance Category, 2021 Call for Measures Submission Form
2021 > (PI Performance Category) Data Submission (see SS-A Table 18)
2021 > (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)	CMS-10621, CMS-10621	Hardship Exception Application Form ,   Extreme and Uncontrollable Circumstances Application Form
2021 > (Physician Compare) Opt Out for Voluntary Participants (see SS-A Table 28)
2021 > (Quality Performance Category) CMS Web Interface Submission Type (see SS-A Table 13)
2021 > (Quality Performance Category) Call for Quality Measures (see SS-A Table 15)	CMS-10621, CMS-10621	Peer Reviewed Journal Article Requirement Template ,   Measures under Consideration 2019, Data Template for Candidate Measures
2021 > (Quality Performance Category) Claims Collection Type (see Table SS-A 10)
2021 > (Quality Performance Category) QCDR/MIPS CQM Collection Type (see SS-A Table 11)
2021 > (Quality Performance Category) Registration and Enrollment for CMS Web Interface (see SS-A Table 14)
2021 > (Quality Performance Category) eCQM Collection Type (see SS-A Table 12)
2021 > Nomination of MVPs (SS-A Table 23)	CMS-10621	Stakeholder Submissions of MIPS Value Pathways (MVP) Candidates: Instructions and Template
2021 > Open Authorization Credentialing and Token Request Process (SS-A Table 5)
2021 > Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 26)	CMS-10621	Eligible Clinician Initiated Submission Form
2021 > Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 25)	CMS-10621	Payer Initiated Submission Form
2021 > Partial Qualifying APM Participant (QP) Election (see SS-A Table 24)
2021 > QPP Identity Management Application Process (see SS-A Table 9)
2021 > Self-nomination: QCDR and Qualified Registry (see SS-A Tables 3 and 4)	CMS-10621	2021 Qualified Clinical Data Registry (QCDR) Measure Submission Template
2021 > Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 27)	CMS-10621	Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option
2022 >> (Improvement Activities Performance Category) Data Submission (see SS-A Table 21)
2022 >> (Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 22)	CMS-10621	Improvement Activities Performance Category, 2021 Call for Activities Submission Form
2022 >> (PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 19)	CMS-10621	Promoting Interoperability Performance Category, 2021 Call for Measures Submission Form
2022 >> (PI Performance Category) Data Submission (see SS-A Table 18)
2022 >> (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)	CMS-10621, CMS-10621	Hardship Exception Application Form ,   Extreme and Uncontrollable Circumstances Application Form
2022 >> (Physician Compare) Opt Out for Voluntary Participants (see SS-A Table 28)
2022 >> (Quality Performance Category) Call for Quality Measures (see SS-A Table 15)	CMS-10621, CMS-10621	Peer Reviewed Journal Article Requirement Template ,   Measures under Consideration 2019, Data Template for Candidate Measures
2022 >> (Quality Performance Category) Claims Collection Type (see Table SS-A 10)
2022 >> (Quality Performance Category) QCDR/MIPS CQM Collection Type (see SS-A Table 11)
2022 >> (Quality Performance Category) eCQM Collection Type (see SS-A Table 12)
2022 >> Nomination of MVPs (SS-A Table 23)	CMS-10621	Stakeholder Submissions of MIPS Value Pathways (MVP) Candidates: Instructions and Template
2022 >> Open Authorization Credentialing and Token Request Process (SS-A Table 5)
2022 >> Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 26)	CMS-10621	Eligible Clinician Initiated Submission Form
2022 >> Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 25)	CMS-10621	Payer Initiated Submission Form
2022 >> Partial Qualifying APM Participant (QP) Election (see SS-A Table 24)
2022 >> QPP Identity Management Application Process (see SS-A Table 9)
2022 >> Self-nomination: QCDR and Qualified Registry (see SS-A Tables 3 and 4)	CMS-10621	2021 Qualified Clinical Data Registry (QCDR) Measure Submission Template
2022 >> Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 27)	CMS-10621	Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	654,162	475,198	175	25	178,764	0
Annual Time Burden (Hours)	2,957,004	2,937,891	3,062	-210	16,261	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The finalized changes in this 2021 collection of information request are associated with our December 28, 2020 (85 FR 84472) final rule (CMS-1734-F, RIN 0938-AU10). Overall we estimate an increase of 19,113 hours. See section 15 of the attached Supporting Statement for details.

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Annual Cost to Federal Government: $167

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/04/2021

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