2021 > (Quality Performance Category) Registration and Enrollment for CMS Web Interface (see SS-A Table 14)

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

Appendix N1 2020 CMS WI and CAHPS Registration Guide

2021 > (Quality Performance Category) Registration and Enrollment for CMS Web Interface (see SS-A Table 14)

OMB: 0938-1314

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1314 can be found here:

Document [pdf]

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2020 Registration Guide for the CMS Web
Interface and the CAHPS for MIPS Survey

Table of Contents
Section
I.

Introduction

Page Number
2

II.

Get Started

III.

Access the CMS Web Interface and/or the CAHPS for MIPS
Survey Registration System

IV.

Submit a New Registration for the CMS Web Interface and/or
the CAHPS for MIPS Survey Registration

Modify Information for a Group with an Existing Registration for
the CMS Web Interface and/or the CAHPS for MIPS Survey
Interface Registration

VI.

View your CMS Web Interface and/or the CAHPS for MIPS
Survey Registration Summary

VII.

Cancel Your Registration for the CMS Web Interface and/or the
CAHPS for MIPS Survey

I. Introduction
This guide provides information and instructions on the registration process for groups, virtual
groups, or Alternative Payment Model (APM) Entities (Accountable Care Organizations (ACOs))
participating in the Medicare Shared Savings Program (MSSP) or Next Generation ACO Model)
− which are collectively referred to as “organizations”− that want to submit their Merit-based
Incentive Payment System (MIPS) quality data through the CMS Web Interface and/or
administer the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS
Survey for the 2020 performance period.
For additional information visit the following resources:
•

The 2020 CMS Web Interface Quick Start Guide for more information about quality
data submissions through the CMS Web Interface.

•

The 2020 CAHPS for MIPS Survey Overview Fact Sheet for more information about
administering the CAHPS for MIPS Survey.

You can find additional information about the Quality Payment Program on qpp.cms.gov.

Have questions? Contact the Quality Payment Program
Phone: 1-866-288-8292 (Customers who are hearing impaired can dial 711 to be connected
to a TRS Communications Assistant) | Email: [email protected]
Available Monday – Friday, 8 a.m. – 8 p.m. ET

Registration Information
To register to submit quality data through the CMS Web Interface and/or administer the CAHPS
for MIPS Survey, sign in to qpp.cms.gov.
Registration opens on Wednesday, April 1, 2020 at 10:00 a.m. Eastern Time (ET) and closes on
Tuesday, June 30, 2020 at 8:00 p.m. ET.
To complete your organization’s registration, you need a HARP account and the Security
Official role for your organization. More information is provided in Section III: Access the
Registration System of this guide.

Definitions
•

Group: A single Taxpayer Identification Number (TIN) with 2 or more clinicians (including at
least one MIPS eligible clinician), as identified by their individual National Provider Identifier
(NPI), who have reassigned their Medicare billing rights to the TIN.

•

Virtual group: A combination of 2 or more whole TINs (solo practitioners and/or groups with
10 or fewer clinicians, including at least one MIPS eligible clinician) whose clinicians elected to
participate in MIPS as part of a virtual group. For the 2020 performance period, only virtual
groups that we approve and identify as official virtual groups can participate in MIPS as a
virtual group.

•

APM Entity group: The group of eligible clinicians participating in an APM Entity, as identified
by a combination of the APM identifier, APM Entity identifier, Taxpayer Identification Number
(TIN), and National Provider Identifier (NPI) for each participating eligible clinician.

Who can register?
1. CMS Web Interface registration is open to groups, virtual groups, and APM Entities with 25
or more clinicians.
o

EXCEPTION: CMS Web Interface registration is NOT open to APM Entities (i.e.
ACOs) participating in the MSSP or Next Generation ACO Model. Reporting quality
data via the CMS Web Interface is required for these ACOs and as a result, they do
not need to register.
▪ However, ACO participant TINs in these entities can still register for the CMS
Web Interface if their ACO is unable to successfully report.

2. CAHPS for MIPS Survey registration is open to
groups, virtual groups, and APM Entities with 2 or
more eligible clinicians.
o

Please note that APM Entities (i.e. ACOs)
participating in the Medicare Shared Savings
Program or Next Generation ACO Model are
already required to administer the CAHPS for
ACO Survey.

Before You Register: The CAHPS for
MIPS Survey assesses the experience of
patients receiving primary care services
and is therefore, most appropriate for
groups, virtual groups, and APM Entities
that provide primary care services.

Who needs to register?
1. Groups, virtual groups, or APM Entities with 25 or more clinicians that did not use the CMS
Web Interface to submit quality data for the 2019 performance period, but plan to for the
2020 performance period.
You were automatically registered if
o Why? Groups that submitted quality data
you submitted quality data through the
through the CMS Web Interface for the 2019
CMS Web Interface in 2019.
performance period have been automatically
Sign in to qpp.cms.gov and review
registered for the 2020 performance period.
your registration to verify the
Automatic CMS Web Interface registrations
information (such as group size and
can be edited (i.e., update group information)
contact information) is correct.
or cancelled for the 2020 performance period.
2. Groups, virtual groups, or APM Entities with 2 or more
eligible clinicians that plan to administer the CAHPS for MIPS Survey for the 2020
performance period.

o Why? There is no automatic registration for the CAHPS for MIPS Survey.
Organizations that plan to administer the CAHPS for MIPS Survey must register
each performance period that they plan to administer the CAHPS for MIPS Survey.

Who does not need to register?
1. Groups, virtual groups, or APM Entities that plan to submit Medicare Part B Claims measures,
electronic Clinical Quality Measures (eCQMs), MIPS Clinical Quality Measures (CQMs) and/or
Quality Clinical Data Registry (QCDR) measures for the 2020 performance period.
o

Why? Registration is not required for these collection types.

2. Groups that submitted quality data through the CMS Web Interface for the 2019 performance
period.
o

Why? Groups have been automatically registered to submit data for the Quality
performance category through the CMS Web Interface for the 2020 performance
period. Automatic CMS Web Interface registrations can be edited (i.e., update group
information) or cancelled for the 2020 performance period.

3. ACOs participating in a Medicare Shared Savings Program or the Next Generation ACO
Model.
o

Why? An ACO is required to submit quality data through the CMS Web Interface and
no registration is needed. The quality data submitted through the CMS Web Interface
by an ACO is used to score the MIPS Quality performance category; the score will
apply to each MIPS eligible clinician in the ACO who is scored under the APM scoring
standard.

However, ACO Participant TINs can register to submit data at the group level if, for
example, an ACO Participant TIN is terminating its ACO participation agreement or
have concerns that the ACO will not be able to successfully report on behalf of the
ACO Participant TINs.

Do we have to submit data through the CMS Web Interface if we’re registered?
No, registered organizations do not have to submit quality data through the CMS Web Interface
but would need to select a different submission type (i.e., Electronic Health Record (EHR),
Qualified Registry, Qualified Clinical Data Registry (QCDR)) in order to submit quality.
However, organizations that do not plan to submit quality data through the CMS Web Interface
are strongly encouraged to cancel their registration by 8:00pm ET on June 30, 2020.
If organizations do not cancel their registration before the deadline, they can still submit quality
data through other submission types.

Is it possible for my organization to be unable to report through the CMS Web
Interface?
For organizations that are registered for the CMS Web Interface, we conduct an assignment
and sampling methodology process. Generally, we assign patients to the organizations that
furnished the plurality of primary care services for such patients.
In rare instances, an organization may have 0 Medicare patients assigned to them and as a
result, we can’t populate a patient sample. If a patient sample can’t be populated, the
organization will not be able to submit quality data through the CMS Web Interface.
If an organization does not have any Medicare patients assigned for any of the CMS Web
Interface measures, the following will occur:
•

We will notify the organizations that they can’t submit quality data through the CMS Web
Interface. We anticipate notifications will be sent in the Fall of 2020.

The organization won’t meet the CMS Web Interface data submission criteria and will need to
submit quality measures from another collection type (i.e., eCQMs or MIPS CQMs).

Is it possible we won’t be able to administer the CAHPS for MIPS Survey?
For the 2020 performance period, the CAHPS for MIPS Survey continues to be optional.
For organizations that are registered to administer the CAHPS for MIPS Survey, we conduct an
assignment and sampling methodology process. Groups and virtual groups must meet minimum
patient sampling requirements in order to administer the 2020 CAHPS for MIPS Survey.
If an organization does not meet the minimum patient sampling requirements for the CAHPS for
MIPS Survey, we will notify organizations indicating that they will not be able to administer the
CAHPS for MIPS Survey. We anticipate notifications to be sent in the Fall of 2020.
Organizations that don’t meet minimum patient sampling requirements:
•

Will not be able to attest to Participation in CAHPS or Other Supplemental Questionnaire
(IA_PSPA_11) and will need to select a different activity for the Improvement Activities
performance category.

•

Will not be able to supplement their quality score with points associated with the
administration of the CAHPS for MIPS Survey.

•

May qualify for a denominator reduction in the Quality performance category if not
submitting quality data through the CMS Web Interface.

II. Get Started
Obtain Access
A representative of the group, virtual group, or APM Entity will need an account that allows the
representative to sign in to qpp.cms.gov and have the Security Official role for the
organization in order to submit, modify, or cancel a registration.
•

If you’re a returning user, sign in with your existing QPP account
credentials.

•

If you’re a new user, you’ll need to create an account before you can
request Security Official access to your organization by signing in to
qpp.cms.gov.

Visit the QPP Access User Guide on the Resource Library for
instructions to create an account and/or request the Security Official role
for your organization.
•

•

Connect to an Organization provides information about requesting
the Security Official role for your organization.

Start the account
creation process
now to avoid any
last-minute delays
in obtaining an
account and a role
with your
organization. The
registration period
closes on June 30,
2020 at 8:00 p.m.
ET.

To determine if your organization already has an individual who can register the group, virtual
group, or APM Entity for the CMS Web Interface and/or to administer the CAHPS for MIPS
Survey, please contact the Quality Payment Program using the contact information at the bottom
of this page and provide the group's TIN, the virtual group identifier, or the APM Entity identifier,
and the name of the organization.
Prepare to Register for the CMS Web Interface and/or the CAHPS for MIPS Survey
Gather the following information before you begin to register your group, virtual group, and APM
Entity:
•

Organization Information: Organization Name and Mailing Address.

•

Contact Information: First Name, Last Name, Phone Number and E-Mail.
o

Note: You must provide complete information for at least one contact to submit your
registration; all contacts will be notified by e-mail when a registration is submitted,
modified, or cancelled.

•

Determine Organization Size: 2-24 clinicians, 25-99 clinicians, or 100 or more clinicians.

•

Determine Registration Selection: the CMS Web Interface (25 or more clinicians) and/or the
CAHPS for MIPS Survey. (2 or more eligible clinicians)
Have questions? Contact the Quality Payment Program
Phone: 1-866-288-8292 (Customers who are hearing impaired can dial 711 to be connected
to a TRS Communications Assistant) | Email: [email protected]
Available Monday – Friday, 8 a.m. – 8 p.m. ET

III. Access the CMS Web Interface and/or the CAHPS for MIPS Survey
Registration System
You will be able to access the registration system between April 1, 2020 (10:00 a.m. ET) and
June 30, 2020 (8:00 p.m. ET) by signing in to the qpp.cms.gov.
Signing in to qpp.cms.gov will allow you to create new registrations, view or cancel existing
registrations (including an automatic CMS Web Interface registration), or modify information for
existing registrations (including an automatic CMS Web Interface registration).
1. Sign In
Go to https://qpp.cms.gov/login or click Sign In in the upper right-hand corner of qpp.cms.gov.
2. Enter User ID and Password
Enter your User ID and Password in the requested fields, check “Yes, I agree” next to the
Statement of Truth, and Sign In (you will be prompted to provide a security code from your
two-factor authentication).

Returning users
Sign in with your previously
created HARP credentials
New users
Sign in with your newly created
HARP credentials
Don’t have an Account?
Click the Register tab next to
the Sign In tab and review the
QPP Access User Guide

3. Complete the Two-Factor Authentication
If this is your first time signing in, you will be prompted to set up two-factor authentication
which will be completed in your HARP account. You will select a verification device (i.e. your
cell phone) where you wish to have your one-time code sent each time you sign in.
If you’re a returning user, you will simply select the registered verification device you wish to
have the one-time code sent to.

Request a one-time code by selecting your preferred device from the device dropdown, click
Send Code, enter the one-time code, and click Verify.
Step 1. Select device from device drop
down and send code.

Step 2. Type in code and verify.

4. Manage Access
Select Manage Access from the left-hand navigation panel.

5. Connected Practices
Review your Connected Organizations to see if your organization has an active registration
for the CMS Web Interface and/or the CAHPS for MIPS Survey.
An active registration is indicated by Registered in green text with a green check checkmark.

6. Register or Edit Registration
Click the Edit Registration button to the right of the CMS Web Interface & CAHPS section or
below the CMS Web Interface and CAHPS section under the organization you’re interested in
registering or making an edit to its registration.
Selecting Edit Registration will allow you to submit a new registration as well as modify or
cancel an existing registration for your organization.

If you don’t see Edit Registration, then you do not have the
required Security Official role in for any connected organization(s).
This role is necessary to submit, modify, or cancel a registration.
Visit Review the Connect to an Organization section in the QPP
Access User Guide for information about obtaining the correct
Security Official role.

IV. Submit a New Registration for the CMS Web Interface and/or the
CAHPS for MIPS Survey
After selecting Edit Registration, you will be taken to the main registration page where you will
see a list of organizations for which you have you have a Security Official role.

Follow the steps below whether you are registering an organization for the first time or reregistering an organization that cancelled a previous registration.

If you don’t see an organization that you expected to
see, you don’t have the required Security Official role for
that organization. This role is necessary to submit or
cancel a registration.
Review Connect to an Organization in the QPP Access
User Guide for information about obtaining this role.

1. Organization Size
Select the Organization Size next to the organization you want to register.
•

2-24 clinicians will allow you to register for the CAHPS for MIPS survey.

•

25-99 or 100 or greater clinicians will allow you to register for the CMS Web Interface
and/or the CAHPS for MIPS Survey.

2. Register
Click Register under “CMS Web Interface” (which will only display if your organization size
allows it) or “CAHPS for MIPS Survey”.
Note: This section uses the CMS Web Interface registration as the example, but the same
steps apply if you’re registering to administer the CAHPS for MIPS Survey.

3. Submit Registration
To submit your registration, you will need to complete any required organization and contact
information. You will see limited organization and contact information populated.
Select Edit next to the organization to complete any missing required information.

4. Review Organization Information
Review the Organization Information that is pre-populated for your group or
virtual group and update it as necessary.
A green checkmark will appear after you enter each piece of required information. Once all
required information has been entered, you will be able to select Update.

Can update:
•
•
•
•
•

Organization name
Address
City
State
Zipcode

Can’t update:
•
•

Group size*
TIN, virtual group ID, or APM
Entity ID**

*Group size can only be edited on the main registration page.
**TIN, virtual group ID, and APM Entity ID cannot be edited.

Edit Registration
After the organization information has been updated, under Contact Information select Edit
to complete the remaining required information.

6. Review Contact Information
Contact information will be partially pre-populated with the first and last name associated with
your HARP account.
•

To keep yourself as a contact for the organization’s registration, simply add your e-mail
address and phone number, and then select Update. (Don’t worry – you can add
additional contacts!)

•

If you should not be a contact for the organization’s registration, update the first and last
name, add the appropriate contact’s e-mail address and phone number, and then select
Update.

7. Add New Contact
Add any additional contact by selecting Add New, where you will be prompted to provide first
and last name, e-mail address, and phone n umber. Otherwise, select Register. (You can add
additional contacts at any point during the registration period.)

8. Congratulations, you have successfully registered!
You will see your registration identification number displayed on the screen. Each
organization receives a single registration identification number that will not change whether
you modify, cancel, or add a new registration. All of the contacts associated with the
registration will also receive an e-mail notification of the successful registration.
Select Back to List to complete another registration for the same organization, or to register
another organization for the CMS Web Interface and/or the CAHPS for MIPS Survey.

9. Confirm Registration on the Registration Overview Page
On the Registration Overview page, confirm that you see a green checkmark next to “CMS
Web Interface” (and/or “CAHPS for MIPS Survey”). The green checkmark indicates your
successful registration for your organization.
Note: If you’re adding a second registration for the same organization (i.e. registering for the
CAHPS for MIPS Survey after registering for the CMS Web Interface), the organization and
contact information will carry over and you will only need to follow Steps 2 and 8.

V. Modify Information for an Organization with an Existing
Registration for the CMS Web Interface and/or the CAHPS for MIPS
Survey
If you need to modify information for your organization that has an existing registration for the
CMS Web Interface and/or the CAHPS for MIPS Survey for the 2020 performance period, you
may do so at any time during the registration period between April 1, 2020 at 10:00 a.m. and
June 30, 2020 at 8:00 p.m. ET.
You may need to modify your information for any of the following reasons:
•

•

You were automatically registered for the CMS Web Interface and:
o

The Organization Size from your registration is no longer accurate.

The Organization Address from your 2019 registration is no longer accurate.

The Contact Information (name, e-mail address, and/or phone number) from your
2019 registration is no longer accurate.

You registered for the CMS Web Interface this performance year and:
o

You need to update the Organization Address.

You need to update Contact Information, or change the Contacts associated with the
organization’s registration.

Complete the steps in Section III: Access the Registration System of this guide before modifying
your organization information.

Update Organization Size
To edit the size of your organization, select Edit next to Size. Select the correct organization
size and confirm or cancel the change.

Note: If you are currently registered for the CMS Web Interface and select 2-24 as the
organization size, the confirmation message will indicate that accepting the change in size will
cancel any existing CMS Web Interface registration because the CMS Web Interface is only
available to organizations with 25 or more clinicians (including at least one MIPS eligible
clinician).

Update Organization/Contact Information
To update the organization or contact information, select Show Details below the
organization’s TIN, virtual group ID, or APM Entity ID.

Update Organization Address
To update the organization’s address, select Edit, which will allow you to update the address,
city, state, and zip code as needed.

Update Existing Contact
To Edit or Delete an existing contact, select the appropriate option under the contact.
Note: The system requires that there is at least one contact for a registration. If your
organization only has one contact identified and the contact needs to be changed, you will
need to select Edit (not Delete), which will allow you to change the first and last name, e-mail
address, and phone number.

Add New Contact
To add a new contact, select Add New Contact; you will be prompted to provide the contact’s
first and last name, email address, and phone number.

VI. View your CMS Web Interface and/or the CAHPS for MIPS Survey
Registration Summary
The registration system will allow you to view information about the CMS Web Int erface and/or
the CAHPS for MIPS Survey registrations for all the organizations for which you have a Security
Official role.
A green checkmark indicates an existing registration, and a yellow semi-circle indicates there is
no registration.

In the below screenshot, Sample Organization is registered for the CMS Web Interface, but not
registered to administer the CAHPS for MIPS Survey.
Select Show Detail to display the Organization and Contact Information.

Note: Each organization will receive a single registration identification number to track all
registration activity.
To view your organization’s registration information, follow the steps in Section III: Access the
Registration System of this guide.

VII. Cancel Your 2020 Registration for the CMS Web Interface and/or
the CAHPS for MIPS Survey
If your organization is registered to participate in MIPS utilizing the CMS Web Interface and/or
administering the CAHPS for MIPS Survey for the 2020 performance period, but wishes to
cancel one or both registrations, you can log in to the registration system and cancel your
registration any time before the registration period closes on June 30, 2020 at 8:00 p.m. ET.
If you want to re-register the organization during the 2020 registration period after cancelling
your registration, please refer to Section IV: Submit a New Registration of this guide.
Cancel Registration
1. Complete the steps in Section III: Access the Registration System of this guide.
2. Select Cancel Registration under the appropriate registration.

3. Once you select Cancel Registration, you will be required to click Continue to cancel your
registration or if you change your mind, click Cancel.

4. You have successfully cancelled your registration! Record the registration identification
number provided in the e-mail notification for your records.
If you need to contact the Quality Payment Program to discuss your registration, please
provide the registration identification number. All the contacts associated with the registration
will also receive an e-mail with the registration identification number confirming your
registration cancellation.
Have questions? Contact the Quality Payment Program
Phone: 1-866-288-8292 (Customers who are hearing impaired can dial 711 to be connected
to a TRS Communications Assistant) | Email: [email protected]
Available Monday – Friday, 8 a.m. – 8 p.m. ET

5. When you return to the list of Connected Organizations, you should see that the organization
is no longer registered for the CMS Web Interface.

Note: If you did not intend to cancel the organization’s registration, please follow the guidance
in Section IV: Submit a New Registration of this guide to re-register your organization before
the 2020 registration period closes on June 30, 2020 at 8:00p.m. ET.
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. The time required to complete this
information collection is estimated to average 0.25 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.
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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 [email protected].

File Type	application/pdf
File Title	2020 Registration Guide for the CMS Web Interface and the CAHPS for MIPS Survey
Author	HHS/CMS
File Modified	2020-12-03
File Created	2020-03-31