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 2021 CMS Web Interface and CAHPS for MIPS Registration Guide	Form and Instruction	New	Available
Form CMS-10621 Quality Data Submission via the CMS Web Interface (SS-A Table 16)	Form and Instruction	New	Repair queued
Form CMS-10621 Stakeholder Submissions of MIPS Value Pathways (MVP) Candidates: Instructions and Template	Form and Instruction	Modified	Available
Form CMS-10621 Nomination of MVPs (SS-A Table 28)	Form and Instruction	Modified	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 32)	Form	Modified	Available
Form CMS-10621 Measures under Consideration 2021, 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 18)	Form and Instruction	Modified	Repair queued
Form CMS-10621 Appendix E1 2022 Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submission Fo	Form	Modified	Available
Form CMS-10621 Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 31)	Form	Modified	Repair queued
Form CMS-10621 Promoting Interoperability Performance Category, 2022 Call for Measures Submission Form	Form and Instruction	Modified	Available
Form CMS-10621 (PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 23)	Form and Instruction	Modified	Repair queued
Form CMS-10621 2022 Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form)	Form and Instruction	Modified	Available
Form CMS-10621 Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 30)	Form and Instruction	Modified	Repair queued
Form CMS-10621 Improvement Activities Performance Category, 2021 Call for Activities Submission Form	Form	Modified	Repair queued
Form CMS-10621 (Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 27)	Form	Modified	Repair queued
Form CMS-10621 Extreme and Uncontrollable Circumstances Application Form	Form	Modified	Available
Form CMS-10621 Hardship Exception Application Form	Form	Modified	Available
Form CMS-10621 (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 19)	Form	Modified	Repair queued
Form CMS-10621 Partial QP Election Form	Form and Instruction	Modified	Available
Form CMS-10621 Partial Qualifying APM Participant (QP) Election (see SS-A Table 29)	Form and Instruction	Modified	Repair queued
Form CMS-10621 2021 Qualified Clinical Data Registry (QCDR) Measure Submission Template	Form	Modified	Available
Form CMS-10621 Stakeholder Submissions of MIPS Value Pathways (MVP) Candidates: Instructions and Template	Form and Instruction	Modified	Available
Form CMS-10621 Nomination of MVPs (SS-A Table 28)	Form and Instruction	Modified	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 32)	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 18)	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 31)	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 23)	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 30)	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 27)	Form	Modified	Repair queued
Form CMS-10621 Extreme and Uncontrollable Circumstances Application Form	Form	Modified	Available
Form CMS-10621 Hardship Exception Application Form	Form	Modified	Available
Form CMS-10621 (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 19)	Form	Modified	Repair queued
Form CMS-10621 2021 Qualified Clinical Data Registry (QCDR) Measure Submission Template	Form	Modified	Available
CMS-10621 - Supporting Statement B.pdf	Supporting Statement B	Uploaded 2021-09-30	Repair queued
CMS-10621 - Supporting Statement A (CMS-1751-P version 10) - Clean.docx	Supporting Statement A	Uploaded 2021-09-30	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
249143	2022 >> Group Registration for CMS Web Interface (SS-A Table 17)		New
249142	2022 >> Quality Data Submission via the CMS Web Interface (SS-A Table 16)	Form and Instruction	New	2021 CMS Web Interface and CAHPS for MIPS Registration Guide
249142	Quality Data Submission via the CMS Web Interface (SS-A Table 16)	Form and Instruction	New
248666	2023 > MVP Quality Submission: 2023 Performance Period (SS-A Table 15)		New
248665	2023 > Subgroup Registration: 2023 Performance Period (SS-A Table 14)		New
248664	2023 > MVP Registration: 2023 Performance Period (SS-A Table 13)		New
245893	2022 >> Open Authorization Credentialing and Token Request Process (SS-A Table 5)		Modified
245892	2022 >> Nomination of MVPs (SS-A Table 28)	Form and Instruction	Modified	Stakeholder Submissions of MIPS Value Pathways (MVP) Candidates: Instructions and Template
245892	Nomination of MVPs (SS-A Table 28)	Form and Instruction	Modified
245891	2022 >> Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 32)	Form	Modified	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 32)	Form	Modified
245886	2022 >> QPP Identity Management Application Process (see SS-A Table 9)		Unchanged
245885	2022 >> (Quality Performance Category) Call for Quality Measures (see SS-A Table 18)	Form and Instruction	Modified	Measures under Consideration 2021, Data Template for Candidate Measures
245885	2022 >> (Quality Performance Category) Call for Quality Measures (see SS-A Table 18)	Form and Instruction	Modified	Peer Reviewed Journal Article Requirement Template
245885	(Quality Performance Category) Call for Quality Measures (see SS-A Table 18)	Form and Instruction	Modified
245884	2022 >> Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 31)	Form	Modified	Appendix E1 2022 Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submission Fo
245884	Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 31)	Form	Modified
245883	2022 >> (PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 23)	Form and Instruction	Modified	Promoting Interoperability Performance Category, 2022 Call for Measures Submission Form
245883	(PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 23)	Form and Instruction	Modified
245882	2022 >> (Physician Compare) Opt Out for Voluntary Participants (see SS-A Table 33)		Modified
245881	2022 >> Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 30)	Form and Instruction	Modified	2022 Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form)
245881	Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 30)	Form and Instruction	Modified
245880	2022 >> (Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 27)	Form	Modified	Improvement Activities Performance Category, 2021 Call for Activities Submission Form
245880	(Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 27)	Form	Modified
245879	2022 >> (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 19)	Form	Modified	Extreme and Uncontrollable Circumstances Application Form
245879	2022 >> (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 19)	Form	Modified	Hardship Exception Application Form
245879	(PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 19)	Form	Modified
245877	2022 >> Partial Qualifying APM Participant (QP) Election (see SS-A Table 29)	Form and Instruction	Modified	Partial QP Election Form
245877	Partial Qualifying APM Participant (QP) Election (see SS-A Table 29)	Form and Instruction	Modified
245875	2022 >> (Improvement Activities Performance Category) Data Submission (see SS-A Table 25)		Modified
245874	2022 >> (PI Performance Category) Data Submission (see SS-A Table 21)		Modified
245873	2022 >> Self-nomination: QCDR and Qualified Registry (see SS-A Tables 3 and 4)	Form	Modified	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	Modified
245870	2022 >> (Quality Performance Category) eCQM Collection Type (see SS-A Table 12)		Modified
245869	2022 >> (Quality Performance Category) QCDR/MIPS CQM Collection Type (see SS-A Table 11)		Modified
245867	2022 >> (Quality Performance Category) Claims Collection Type (see Table SS-A 10)		Modified
245240	2023 > Open Authorization Credentialing and Token Request Process (SS-A Table 5)		Modified
245229	2023 > Nomination of MVPs (SS-A Table 28)	Form and Instruction	Modified	Stakeholder Submissions of MIPS Value Pathways (MVP) Candidates: Instructions and Template
245229	Nomination of MVPs (SS-A Table 28)	Form and Instruction	Modified
233582	2023 > Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 32)	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 32)	Form	Modified
233581	2023 > QPP Identity Management Application Process (see SS-A Table 9)		Modified
229086	2023 > (Quality Performance Category) Call for Quality Measures (see SS-A Table 18)	Form and Instruction	Modified	Measures under Consideration 2019, Data Template for Candidate Measures
229086	2023 > (Quality Performance Category) Call for Quality Measures (see SS-A Table 18)	Form and Instruction	Modified	Peer Reviewed Journal Article Requirement Template
229086	(Quality Performance Category) Call for Quality Measures (see SS-A Table 18)	Form and Instruction	Modified
229075	2023 > Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 31)	Form	Modified	Eligible Clinician Initiated Submission Form
229075	Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 31)	Form	Modified
229074	2023 > (PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 23)	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 23)	Form and Instruction	Modified
227511	2023 > (Physician Compare) Opt Out for Voluntary Participants (see SS-A Table 33)		Modified
227509	2023 > Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 30)	Form and Instruction	Modified	Payer Initiated Submission Form
227509	Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 30)	Form and Instruction	Modified
227507	2023 > (Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 27)	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 27)	Form	Modified
227506	2023 > (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 19)	Form	Modified	Extreme and Uncontrollable Circumstances Application Form
227506	2023 > (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 19)	Form	Modified	Hardship Exception Application Form
227506	(PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 19)	Form	Modified
227505	2021 > (Quality Performance Category) Registration and Enrollment for CMS Web Interface (see SS-A Table 14)	Instruction	Removed
221786	2023 > Partial Qualifying APM Participant (QP) Election (see SS-A Table 29)		Modified
221785	2023 > (Improvement Activities Performance Category) Data Submission (see SS-A Table 26)		Modified
221784	2023 > (PI Performance Category) Data Submission (see SS-A Table 22)		Modified
221782	2023 > 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	2023 > 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)		Removed
221780	2023 > (Quality Performance Category) eCQM Collection Type (see SS-A Table 12)		Modified
221779	2023 > (Quality Performance Category) QCDR/MIPS CQM Collection Type (see SS-A Table 11)		Modified
221777	2023 > (Quality Performance Category) Claims Collection Type (see Table SS-A 10)		Modified

ICR Details

OMB Control No: 0938-1314	ICR Reference No: 202107-0938-013
Status: Historical Inactive	Previous ICR Reference No: 202101-0938-003
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: Comment filed on proposed rule and continue	Conclusion Date: 11/02/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/04/2021
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is not approved at this time. Prior to publication of the final rule, the agency should provide to OMB a summary of all comments received on the proposed information collection and identify any changes made in response to these comments.

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	654,162
Time Burden (Hours)	2,957,004	0	2,957,004
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-AU42	Proposed rulemaking	86 FR 39104	07/23/2021

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 39104	07/23/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 41

table that charts list of burden

IC Title	Form No.	Form Name
2021 > (Quality Performance Category) CMS Web Interface Submission Type (see SS-A Table 13)
2021 > (Quality Performance Category) Registration and Enrollment for CMS Web Interface (see SS-A Table 14)
2022 >> (Improvement Activities Performance Category) Data Submission (see SS-A Table 25)
2022 >> (Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 27)	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 23)	CMS-10621	Promoting Interoperability Performance Category, 2022 Call for Measures Submission Form
2022 >> (PI Performance Category) Data Submission (see SS-A Table 21)
2022 >> (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 19)	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 33)
2022 >> (Quality Performance Category) Call for Quality Measures (see SS-A Table 18)	CMS-10621, CMS-10621	Peer Reviewed Journal Article Requirement Template ,   Measures under Consideration 2021, 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 >> Group Registration for CMS Web Interface (SS-A Table 17)
2022 >> Nomination of MVPs (SS-A Table 28)	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 31)	CMS-10621	Appendix E1 2022 Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submission Fo
2022 >> Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 30)	CMS-10621	2022 Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form)
2022 >> Partial Qualifying APM Participant (QP) Election (see SS-A Table 29)	CMS-10621	Partial QP Election Form
2022 >> QPP Identity Management Application Process (see SS-A Table 9)
2022 >> Quality Data Submission via the CMS Web Interface (SS-A Table 16)	CMS-10621	2021 CMS Web Interface and CAHPS for MIPS Registration Guide
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 32)	CMS-10621	Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option
2023 > (Improvement Activities Performance Category) Data Submission (see SS-A Table 26)
2023 > (Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 27)	CMS-10621	Improvement Activities Performance Category, 2021 Call for Activities Submission Form
2023 > (PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 23)	CMS-10621	Promoting Interoperability Performance Category, 2021 Call for Measures Submission Form
2023 > (PI Performance Category) Data Submission (see SS-A Table 22)
2023 > (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 19)	CMS-10621, CMS-10621	Hardship Exception Application Form ,   Extreme and Uncontrollable Circumstances Application Form
2023 > (Physician Compare) Opt Out for Voluntary Participants (see SS-A Table 33)
2023 > (Quality Performance Category) Call for Quality Measures (see SS-A Table 18)	CMS-10621, CMS-10621	Peer Reviewed Journal Article Requirement Template ,   Measures under Consideration 2019, Data Template for Candidate Measures
2023 > (Quality Performance Category) Claims Collection Type (see Table SS-A 10)
2023 > (Quality Performance Category) QCDR/MIPS CQM Collection Type (see SS-A Table 11)
2023 > (Quality Performance Category) eCQM Collection Type (see SS-A Table 12)
2023 > MVP Quality Submission: 2023 Performance Period (SS-A Table 15)
2023 > MVP Registration: 2023 Performance Period (SS-A Table 13)
2023 > Nomination of MVPs (SS-A Table 28)	CMS-10621	Stakeholder Submissions of MIPS Value Pathways (MVP) Candidates: Instructions and Template
2023 > Open Authorization Credentialing and Token Request Process (SS-A Table 5)
2023 > Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 31)	CMS-10621	Eligible Clinician Initiated Submission Form
2023 > Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 30)	CMS-10621	Payer Initiated Submission Form
2023 > Partial Qualifying APM Participant (QP) Election (see SS-A Table 29)
2023 > QPP Identity Management Application Process (see SS-A Table 9)
2023 > Self-nomination: QCDR and Qualified Registry (see SS-A Tables 3 and 4)	CMS-10621	2021 Qualified Clinical Data Registry (QCDR) Measure Submission Template
2023 > Subgroup Registration: 2023 Performance Period (SS-A Table 14)
2023 > Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 32)	CMS-10621	Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option

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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 proposed changes in this CY 2022 collection of information request are associated with our July 23, 2021 (86 FR 39104) proposed rule (CMS-1734-F, RIN 0938-AU42). The proposed policies impact the burden estimates for the CY 2022 and CY 2023 MIPS performance periods. Overall, we anticipate a reduction of 21,002 responses, 130,826 hours, and $4,864,776 (labor).

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Annual Cost to Federal Government: $176

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: 10/04/2021

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