Form CMS-10621 Improvement Activities Performance Category, 2021 Call f

Improvement Activities Performance Category
Call for Activities Submission Form
Activities recommended for inclusion or modification should be sent using the Improvement
Activities Submission Template (below) to the email: [email protected].
Stakeholders will receive an email confirmation for their submission. Activities submitted by
July 1, 2021 will be considered for inclusion for the Quality Payment Program Year 7 (2023).
Improvement activities submitted after July 1, 2021 will be considered for inclusion in future
years of the Quality Payment Program. All fields of this form must be completed in order for
your submission to be considered.
We also refer submitters to the 2021 MIPS Improvement Activities list on the CMS Quality
Payment Program resource library, which lists the complete Inventory of current
improvement activities for the Quality Payment Program Year 5 (2021). Submitters should
ensure that proposed new activities do not duplicate existing ones.
MIPS improvement activities considered for selection should meet one or more of the
acceptance criteria. The new list of acceptance criteria for CY 2021 and future years is as
follows:
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Relevance to an existing improvement activities subcategory (or a proposed
new subcategory);
Importance of an activity toward achieving improved beneficiary health outcomes;
Importance of an activity that could lead to improvement in practice to reduce health
care disparities;
Aligned with patient-centered medical homes;
Focus on meaningful actions from the person and family’s point of view;
Supports the patient’s family or personal caregiver;
Representative of activities that multiple individual MIPS eligible clinicians or groups
could perform (for example, primary care, specialty care);
Feasible to implement, recognizing importance in minimizing burden, especially for
small practices, practices in rural areas, or in areas designated as geographic HPSAs by
HRSA;
Evidence supports that an activity has a high probability of contributing to
improved beneficiary health outcomes;
Include a public health emergency as determined by the Secretary;

Includes activities which can be linked to existing and related MIPS quality
and cost measures, as applicable and feasible;* or

CMS is able to validate the activity.

*New submission criterion for submissions made in CY 2021

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Proposed New Improvement Activities Recommended for Inclusion in
the Quality Payment Program: Submission Template
Activity Sponsor:

Provide entity name, URL, and individual
contact information: name, address, phone,
email—in case we need to contact submitter.

CMS NPI # or Sponsor Type:

Include NPI number, or indicate other entity type,
e.g. EHR vendor, specialty group, or other—25
words or less.

Activity Title:

Provide the activity title only—10 words or less.

Activity Description:

Provide a brief description of the proposed
activity—300 words or less. Please be as specific
as possible about what the activity entails. E.g.,
“Eligible clinician must
perform/do XXXX.”

Proposed Subcategory:

Select the ONE (1) subcategory under which
your proposed improvement activity best fits
from among the following eight options:
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Achieving Health Equity
Behavioral and Mental Health
Beneficiary Engagement
Care Coordination
Emergency Response and
Preparedness
Expanded Practice Access
Patient Safety and Practice Assessment
Population Management

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Validation of Activity: Supporting
Documentation (e.g., peer-reviewed
articles, other publications, websites)

Provide supporting validation documentation
that indicates that this activity has been used
successfully in the field, and that it can lead to
practice quality improvement and improvement
in patient health, experience, etc. Please provide
citations of or links to established processes,
validated tools, etc., that are referenced in the
activity.

Documentation to Use as Proof of
Activity Completion:

Include data or primary sources that could be
used to substantiate performance of the
improvement activity (e.g. medical charts,
office schedules, data reports, quality
improvement reports or submissions to
funders/payers, meeting minutes).

Level of Effort:

Include data, primary sources or personal
experience to substantiate the level of effort
the submitter anticipates are required to
complete the proposed improvement activity
on an annual basis. (This estimate could be in
hours/days, dollars, staffing needs/FTE,
external resources/supports or any combination
thereof).

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Proposed Modifications to Improvement Activities Recommended for
Inclusion in the Quality Payment Program: Submission Template
Existing IA Proposed to Modify (please
list IA subcategory/number, e.g.,
IA_AHE_1):
Modification proposed: Please check off
the type of modification you are
proposing
Please list the modification you propose
INCLUDING a rationale for why you believe
this modification is warranted.

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Weight
Subcategory
Description

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****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
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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].

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