Form CMS-10621 Peer Reviewed Journal Article Requirement Template

Peer Reviewed Journal Article Requirement Template
Section 101(c)(1) of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires
submission of new measures for publication in applicable specialty-appropriate, peer-reviewed journals prior to
implementing in the Merit-based Incentive Payment System (MIPS).These measures will be submitted by the
Centers for Medicare & Medicaid Services (CMS), to a journal(s) before including any new measure in the final
list of annual clinical quality measures (CQM) under MIPS. The measure steward shall provide the required
information for article submission under the MACRA per CMS “Call for Measures” submission process.
Measure stewards submitting measures into JIRA must complete the required information by the Call for
Measures deadline. Some of the information requested below may be listed in specific fields in the JIRA tool,
however to ensure that CMS has all of the necessary information and to avoid delays in the evaluation of your
submission, please fully complete this form as an attached Word document in JIRA. The information in JIRA
must be consistent with the information below. This includes, but is not limited to:
[Measure Title]
[Domain]
[Meaningful Measure Area (MMA)]

Measure Steward: [Name]
Measure Developer: [Name]
Description:
I.

Statement
• Background (Why is this measure important?)
• Environmental Scan (Are there existing measures in this area?)

II.

Gap Analysis
• Provide Evidence for the Measure (What are the gaps and opportunities to improve care?)
• Expected Outcome (Patient care/patient health improvements, cost savings)
• Recommendation for the Measure (Is it based on a study, consensus opinion, USPSTF
recommendation etc.?)

III.

Reliability/Validity
A. What testing has been performed at the clinician level? Please provide testing results including the
N value, Bonnie test case results, correlation coefficient and any other pertinent information or
values to be considered.
• Reliability Testing Results:
• Validity Testing Results, clinician sites:
• Exclusion frequency:
• What were the minimum sample sizes used for reliability results?
B. Other Information:
• Is it risk adjusted? If so, how?
• What benchmarking information is available?
• Collection Type: Specify the data collection type.

IV.

Endorsement
• Provide NQF endorsement status (and ID) and/or other endorsing body (If measure is only
endorsed for paper records, please note endorsement for only the data source being submitted)

V.

Summary
• Alignment with CMS Meaningful Measures Initiative or MACRA (If applicable)
• Importance to MIPS or other CMS programs
PEER REVIEWED JOURNAL ARTICLE REQUIREMENT TEMPLATE | Revised January 2020

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Rationale: Use of measure for inclusion in program (specialty society, regional collaborative,
other)
Public reporting (if applicable)
Preferable relevant Peer-Reviewed Journal for publication
Rationale as to how the measure correlates to existing cost measures and improvement
activities, as applicable and feasible.

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1314 (Expiration date:
XX/XX/XXXX). The time required to complete this information collection is estimated to average 4 hours per response, including the
time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.
If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS
Disclosure**** Please do not send applications, claims, payments, medical records or any documents containing sensitive information
to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden
approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have
questions or concerns regarding where to submit your documents, please contact QPP at [email protected].

PEER REVIEWED JOURNAL ARTICLE REQUIREMENT TEMPLATE | Revised January 2020