Crosswalk - 2021 CMS Web Interface and CAHPS for MIPS Registration

CAHPS for MIPS Survey and CMS Web Interface Registration Guide
2019 Final Document versus 2020 Final Document

Changes have burden impact: There are no burden impacts associated with policies finalized
in the CY 2021 PFS final rule.
Change #1:
Location:
2019 - Page 1
2020 – Page 1
Reason for Change:
Alignment with current program year
2019 Final Document text:
Title: 2019 Registration Guide for the CMS Web Interface and CAHPS for MIPS Survey
2020 Final Document text:
Title: 2020 Registration Guide for the CMS Web Interface and CAHPS for MIPS Survey

Change #2:
Location:
2019 – Page 2
2020 – Page 3
Reason for Change:
Edited for clarity and alignment with current program year dates, deadlines, links,
resource titles
2019 Final Document text:
Section: Introduction
Content: This guide provides information and instructions on the registration process for
groups and virtual groups 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 2019 performance period.
For additional information on submitting data through the CMS Web Interface or
administering the CAHPS for MIPS Survey, visit the following resources:
• The 2019 CMS Web Interface Fact Sheet for more information about quality data
submissions through the CMS Web Interface.
• The 2019 CAHPS for MIPS Survey Fact Sheet for more information about
administering the CAHPS for MIPS Survey.
You can find additional information about the Quality Payment Program on the Quality
Payment Program website.
2020 Final Document text:
Section: Introduction

Content: 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 Guide for more information about quality data
submissions through the CMS Web Interface.
• The 2020 CAHPS for MIPS Survey 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.

Change #3:
Location:
2019 – Page 3
2020 – Page 3
Reason for Change:
Edited for clarity and alignment with current program year dates, deadlines,
links/resources
2019 Final Document text:
Section: Introduction > Registration Information
Content: To register to submit quality data through the CMS Web Interface and/or
administer the CAHPS for MIPS Survey, sign in to the Quality Payment Program
website. Registration opens on Monday, April 1, 2019 at 10:00am Eastern Time (ET)
and closes on Monday, July 1, 2019 at 5:00 pm ET.
• Groups and virtual groups need an account (user ID and password) to sign into
the Quality Payment Program website.
• Additionally, an individual registering the group or virtual group will need an
appropriate QPP role associated with the group or virtual group. More
information is provided in Section III: Accessing the Registration System.
2020 Final Document text:
Section: Introduction > Registration Information
Content: 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.

Change #4:
Location:
2019 – Page 4
2020 – Page 3
Reason for Change:
Edited for clarity, added APM entity definition for accuracy, alignment with current
program year dates, deadlines, links/resources
2019 Final Document text:
Section: Introduction > Who needs to register?
Content:
• A group is defined as 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.
• A virtual group is a combination of two 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 2019 performance period, only virtual groups that we approve
and identify as official virtual groups can participate in MIPS as a virtual group.
2020 Final Document text:
Section: Introduction > Definitions
Content:
• 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.

Change #5:
Location:
2019 – N/A
2020 – Page 4
Reason for Change:
Edited for clarity

2019 Final Document text:
N/A
2020 Final Document text:
Section: Introduction > Who can register?
Content:
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.

Change #6:
Location:
2019 – Page 3-4
2020 – Page 4
Reason for Change:
Edited for clarity and alignment with current program year dates and deadlines
2019 Final Document text:
Section: Introduction > Who needs to register?
Content:
• Groups or virtual groups with 25 or more clinicians that did not use the CMS
Web Interface to submit quality data for the 2018 performance period, but
plan to for the 2019 performance period.
o Why? Groups that submitted quality data through the CMS Web
Interface for the 2018 performance period have been automatically
registered for the 2019 performance period. Automatic CMS Web
Interface registrations can be edited (i.e., update group information) or
cancelled for the 2019 performance period.
• Groups or virtual groups that plan to administer the CAHPS for MIPS Survey
for the 2019 performance period.
o Why? There is no automatic registration for the CAHPS for MIPS
Survey. Groups and virtual groups that plan to administer the CAHPS

for MIPS Survey must register each performance period they plan to
administer the CAHPS for MIPS Survey.
• Groups that have been automatically registered for the CMS Web Interface
and plan to administer the CAHPS for MIPS Survey.
o Why? There is no automatic registration for the CAHPS for MIPS
Survey. Groups and virtual groups that plan to administer the CAHPS
for MIPS Survey must register each performance period they plan to
administer the CAHPS for MIPS Survey.
o Note, the CAHPS for MIPS Survey assesses the experience of patients
receiving primary care services. The CAHPS for MIPS Survey is most
appropriate for groups and virtual groups that provide primary care
services.
A group is defined as 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.
A virtual group is a combination of two 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 2019
performance period, only virtual groups that we approve and identify as official virtual
groups can participate in MIPS as a virtual group.
2020 Final Document text:
Section: Who needs to register?
Content:
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.
o Why? Groups that submitted quality data through the CMS Web Interface
for the 2019 performance period have been automatically registered 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.
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.
You were automatically registered if you submitted quality data through
the CMS Web Interface in 2019.
Sign in to qpp.cms.gov and review your registration to verify the information
(such as group size and contact information) is correct.

Change #7:
Location:
2019 – Page 4-5
2020 – Page 5
Reason for Change:
Edited for clarity and alignment with current program year dates and deadlines
2019 Final Document text:
Section: Introduction > Who does not need to register?
Content:
• Groups or virtual groups that plan to submit eCQMs, MIPS CQMs and/or QCDR
measures for the 2019 performance period.
o Why? Registration is not required for these collection types.
• Groups that submitted quality data through the CMS Web Interface for the 2018
performance period.
o Why? Groups have been automatically registered to submit data for the Quality
performance category through the CMS Web Interface for the 2019
performance period. Automatic CMS Web Interface registrations can be edited
(i.e., update group information) or cancelled for the 2019 performance period.
o However, groups that have been automatically registered for the CMS Web
Interface and plan to administer the CAHPS for MIPS Survey need to register
for the CAHPS for MIPS Survey for the 2019 performance period. There is no
automatic registration for the CAHPS for MIPS Survey.
• Groups participating in a Medicare Shared Savings Program (SSP) Accountable Care
Organization (ACO).
o Why? An SSP ACO is required to submit quality data through the CMS Web
Interface. The quality data submitted through the CMS Web Interface by the
SSP ACO is used to score the MIPS Quality performance category and the
score will apply to each MIPS eligible clinician in the ACO.
o However, groups can register to submit data at the group (ACO Participant
TIN) level if, for example, a group (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.
2020 Final Document text:
Section: Introduction > Who does not need to register?
Content:
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.

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.
o 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.
o

Change #8:
Location: Page 5
Reason for Change:
Edited for clarity
2019 Final Document text:
Section: Introduction > Groups with clinicians participating in a Next Generation ACO
Model or other (non-SSP) Advanced APM
Content:
• Certain Advanced Alternate Payment Models (Advanced APMs) allow “split
TINs”, where some of the clinicians billing under the group’s Taxpayer
Identification number (TIN) participate in the model while others do not. If a “split
TIN”, particularly the portion of the group (TIN) that is not participating in a Next
Generation ACO Model or other Advanced APM, is eligible to participate in
MIPS, the group can register to submit quality data through the CMS Web
Interface (as long as the MIPS eligible portion of the group has 25 or more
clinicians) and/or administer the CAHPS for MIPS Survey on behalf of the MIPS
eligible clinicians in the group who do not participate in the APM. This would be
separate from any APM Entity reporting required by the model which would only
apply to the clinicians participating in the model.
Who can’t register?
o APM Entities: Medicare Shared Savings Program Accountable Care
Organizations (SSP ACOs) and Next Generation ACO Models.
o Why? ACOs are required to submit quality data through the CMS Web
Interface, so there is no need to register for the CMS Web Interface. The
registration system will not allow registrations at the APM Entity (Primary
TIN) level.
2020 Final Document text:
Section: Introduction > Who does not need to register?
Content: 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.

o

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.

Change #9:
Location: Page 5
Reason for Change:
Edited to align with current program year dates and deadlines
2019 Final Document text:
Section: Introduction > Do we have to submit data through the CMS Web Interface if
we’re registered?
Content: No, registered groups and virtual groups do not have to submit quality data
through the CMS Web Interface. However, groups and virtual groups that do not plan to
submit quality data through the CMS Web Interface are strongly encourage to cancel
their registration by 5:00pm ET on July 1, 2019. If your group or virtual group doesn’t
cancel your registration before this date, you can submit quality measures through other
submission types.
2020 Final Document text:
Section: Introduction > Do we have to submit data through the CMS Web Interface if
we’re registered?
Content: 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.

Change #10:
Location: Page 6
Reason for Change:
Edited for clarity and alignment with current program year dates and deadlines
2019 Final Document text:
Section: Introduction > Is it possible we won’t be able to report through the CMS Web
Interface?

Content: For groups and virtual groups that are registered for the CMS Web Interface,
we conduct an assignment and sampling methodology process. Generally, we assign
beneficiaries to the group or virtual group that furnished the plurality of primary care
services for such beneficiaries.
In rare instances, a group or virtual group may have zero Medicare beneficiaries
assigned to them and as a result, we can’t populate a beneficiary sample. If a
beneficiary sample can’t be populated, the group or virtual group will not be able to
submit quality data through the CMS Web Interface.
If a group or virtual group does not have any Medicare beneficiaries assigned for any of
the CMS Web Interface measures, the following will occur:
• We will notify the groups and virtual groups that they can’t submit quality data
through the CMS Web Interface. We anticipate notifications to be sent in the Fall of
2019.
• The group or virtual group won’t meet the CMS Web Interface data submission
criteria and will need to submit measures from another collection type (such as
eCQMs or MIPS CQMs).
2020 Final Document text:
Section: Introduction > Is it possible for my organization to be unable to report through
the CMS Web Interface?
Content: 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:
o 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).

Change #11:
Location: Page 6
Reason for Change:
Edited for clarity and alignment with current program year dates and deadlines
2019 Final Document text:
Section: Introduction > Is it possible we won’t be able to administer the CAHPS for
MIPS Survey?
Content: For the 2019 performance period, the CAHPS for MIPS Survey continues to be
optional. For groups and virtual groups that are registered to administer the CAHPS for
MIPS Survey, we conduct a process for assigning and sampling beneficiaries. Groups

and virtual groups must meet minimum beneficiary sampling requirements to administer
the 2019 CAHPS for MIPS Survey.
If a group or virtual group does not meet the minimum beneficiary sampling
requirements for the CAHPS for MIPS survey, we will notify groups and virtual groups
indicating that they will not be able to administer the CAHPS for MIPS Survey. We
anticipate notifications to be sent in the Fall of 2019.
Groups and virtual groups that don’t meet minimum beneficiary sampling requirements:
• Will need to select a different activity for the Improvement Activities performance
category
• Will not be able to supplement their quality score from CMS Web Interface measures
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
2020 Final Document text:
Section: Introduction > Is it possible we won’t be able to administer the CAHPS for
MIPS Survey?
Content: 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:
o 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.
o Will not be able to supplement their quality score with points associated with
the administration of the CAHPS for MIPS Survey.
o May qualify for a denominator reduction in the Quality performance category
if not submitting quality data through the CMS Web Interface.

Change #12:
Location: Page 7
Reason for Change:
Edited for clarity
2019 Final Document text:
Section: Get Started
Content: Register for a HARP Account provides information about creating a new HARP
account
2020 Final Document text:
Section: Get Started

Content: Register for a HCQIS Access Roles and Profile (HARP) Account provides
information about creating a new HARP account

Change #13:
Location: Page 7
Reason for Change:
Edited for clarity and alignment with current program year dates and deadlines
2019 Final Document text:
Section: Get Started
Content: Start the account creation process now to avoid any last-minute delays in
obtaining an account and role with your organization. The registration period closes on
July 1, 2019 at 5:00 pm ET.
2020 Final Document text:
Section: Get Started
Content: 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 8:00p.m. ET.

Change #14:
Location: Page 7
Reason for Change:
Edited for clarity
2019 Final Document text:
Section: Get Started
Content: To determine whether your group or virtual group already has an individual
who can register the group or virtual group for the CMS Web Interface and/or to
administer the CAHPS for MIPS survey, please contact the Quality Payment Program
and provide the group's TIN or virtual group ID and the name of the group.
o By phone at 866-288-8292 (TTY 1-877-715-6222)
o By e-mail at [email protected]
2020 Final Document text:
Section: Get Started
Content: 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.

Change #15:
Location: Page 8
Reason for Change:
Edited for clarity and alignment with current program year dates, deadlines,
links/resources
2019 Final Document text:
Section: Access the CMS Web Interface and/or CAHPS for MIPS Survey Registration
System
Content: You will be able to access the registration system between April 1, 2019 and
July 1, 2019 (5:00 pm ET) by signing in to the QPP website. Signing in to qpp.cms.gov
will allow you to create new registrations, view or cancel existing registrations, or modify
information for groups with an existing registration.
1. Go to https://qpp.cms.gov/login or click Sign In in the upper right-hand corner of the
QPP website.
2. 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).
2020 Final Document text:
Section: Access the CMS Web Interface and/or CAHPS for MIPS Survey Registration
System
Content: You will be able to access the registration system between April 1, 2020 (10:00
a.m. ET) and June 30, 2020 (8:00p.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).

Change #16:
Location: Page 9
Reason for Change:
Edited for clarity
2019 Final Document text:
Section: Access the CMS Web Interface and/or CAHPS for MIPS Survey Registration
System

Content:
3. 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 (such as 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.
4. Request a one-time code by selecting your preferred device from the device drop
down and click send code and verify code.
2020 Final Document text:
Section: Access the CMS Web Interface and/or CAHPS for MIPS Survey Registration
System
Content:
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.

Change #17:
Location: Page 10
Reason for Change:
Edited for clarity
2019 Final Document text:
Section: Access the CMS Web Interface and/or CAHPS for MIPS Survey Registration
System
Content:
5. Select Manage Access from the left-hand navigation panel.
2020 Final Document text:
Section: Access the CMS Web Interface and/or CAHPS for MIPS Survey Registration
System
Content:
4. Manage Access
Select Manage Access from the left-hand navigation panel.

Change #18:
Location: Page 11
Reason for Change:
Edited for clarity and alignment with current program year dates and deadlines
2019 Final Document text:
Section: Access the CMS Web Interface and/or CAHPS for MIPS Survey Registration
System
Content:
6. Review your connected organizations to see if your group or virtual group has an
active registration for the CMS Web Interface and/or CAHPS for MIPS Survey. An
active registration is indicated by “Registered” in green text with a green check
checkmark.
2020 Final Document text:
Section: Access the CMS Web Interface and/or CAHPS for MIPS Survey Registration
System
Content:
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.

Change #19:
Location: Page 12
Reason for Change:
Edited for clarity
2019 Final Document text:
Section: Access the CMS Web Interface and/or CAHPS for MIPS Survey Registration
System
Content:
7. Click the Edit Registration button to the right of CMS Web Interface & CAHPS section.
Or click the Edit Registration link below the CMS Web Interface and CAHPS section
under the practice you’re interested in registering for.
Selecting Edit Registration will allow you to submit a new registration as well as
modify or cancel an existing registration for your group or virtual group.
2020 Final Document text:
Section: Access the CMS Web Interface and/or CAHPS for MIPS Survey Registration
System
Content:
8. 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.

Change #20:
Location: Page 13
Reason for Change:
Edited for clarity and alignment with current program year links/resources
2019 Final Document text:
Section: Access the CMS Web Interface and/or CAHPS for MIPS Survey Registration
System
Content: If you don’t see Edit Registration, then you do not have the required Security
Official role in for any connected practice(s). This role is necessary to submit, modify or
cancel a registration. Visit Connect to an Organization in the QPP Access User Guide
for information about obtaining the correct role.
2020 Final Document text:
Section: Access the CMS Web Interface and/or CAHPS for MIPS Survey Registration
System
Content: 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.

Change #21:
Location: Page 13
Reason for Change:
Edited for clarity
2019 Final Document text:
Section: Submit a New Registration for the CMS Web Interface and/or CAHPS for MIPS
Survey
Content: Note: There are a few small differences in the registration process for groups
and virtual groups. These differences will be highlighted throughout this section of the
guide. The main difference is that groups will see their Taxpayer Identification Number
(TIN) listed below their group name while virtual groups will see their virtual group ID.
2020 Final Document text:
Section: Submit a New Registration for the CMS Web Interface and/or CAHPS for MIPS
Survey
Content: Groups will see their Taxpayer Identification Number (TIN) listed below their
group name.

Change #22:
Location: Page 14
Reason for Change:
Edited for clarity
2019 Final Document text:
Section: Submit a New Registration for the CMS Web Interface and/or CAHPS for MIPS
Survey
Content:
1. Select the Group Size next to the group or virtual group 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.
2020 Final Document text:
Section: Submit a New Registration for the CMS Web Interface and/or CAHPS for MIPS
Survey
Content:
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.

Change #23:
Location: Page 14
Reason for Change:
Edited for clarity
2019 Final Document text:
Section: Submit a New Registration for the CMS Web Interface and/or CAHPS for MIPS
Survey
Content:
2. After you identify your group size, you will see the registration options available to
your group or virtual group. Click Register under CMS Web Interface (which will
only display if your group size allows it) or CAHPS for MIPS Survey.
Note: This section uses CMS Web Interface registration as the example, but the
same steps apply if you’re registering to administer the CAHPS for MIPS survey.
2020 Final Document text:
Section: Submit a New Registration for the CMS Web Interface and/or CAHPS for MIPS
Survey

Content:
3. 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.

Change #24:
Location: Page 14
Reason for Change:
Edited for clarity
2019 Final Document text:
Section: Submit a New Registration for the CMS Web Interface and/or CAHPS for MIPS
Survey
Content:
3. To submit your registration, you will need to complete any required Organization and
Contact information. Groups and virtual groups will both see limited group and contact
information populated. Select Edit next to the organization to complete any missing
required information.
2020 Final Document text:
Section: Submit a New Registration for the CMS Web Interface and/or CAHPS for MIPS
Survey
Content:
4. 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.

Change #25:
Location: Page 17
Reason for Change:
Edited for clarity
2019 Final Document text:
Section: Submit a New Registration for the CMS Web Interface and/or CAHPS for MIPS
Survey
Content:
4. Review the organization information that 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.
2020 Final Document text:
Section: Submit a New Registration for the CMS Web Interface and/or CAHPS for MIPS
Survey
Content:
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.

Change #26:
Location: Page 18
Reason for Change:
Edited for clarity
2019 Final Document text:
Section: Submit a New Registration for the CMS Web Interface and/or CAHPS for MIPS
Survey
Content:
5. After the organization information has been updated, under Contact Information select
Edit to complete the remaining required information.
2020 Final Document text:
Section: Submit a New Registration for the CMS Web Interface and/or CAHPS for MIPS
Survey
Content:
5. Edit Registration
After the organization information has been updated, under Contact Information select
Edit to complete the remaining required information.

Change #27:
Location: Page 17
Reason for Change:
Edited for clarity
2019 Final Document text:
Section: Submit a New Registration for the CMS Web Interface and/or CAHPS for MIPS
Survey

Content:
6. Contact information will be partially pre-populated with the first and last name
associated with your HARP account.
2020 Final Document text:
Section: Submit a New Registration for the CMS Web Interface and/or CAHPS for MIPS
Survey
Content:
6. Review Contact Information
Contact information will be partially pre-populated with the first and last name associated
with your HARP account.

Change #28:
Location: Page 18
Reason for Change:
Edited for clarity
2019 Final Document text:
Section: Submit a New Registration for the CMS Web Interface and/or CAHPS for MIPS
Survey
Content:
7. Add any additional contacts by selecting Add New, where you will be prompted to
provide First and Last Name, Email, and Phone Number. Otherwise, select Register. (You
can add additional contacts at any point during the registration period.)
2020 Final Document text:
Section: Submit a New Registration for the CMS Web Interface and/or CAHPS for MIPS
Survey
Content:
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.)

Change #29:
Location:
2019 – Page 21
2020 – Page 19
Reason for Change:
Edited for clarity and accuracy
2019 Final Document text:
Section: Submit a New Registration for the CMS Web Interface and/or CAHPS for MIPS
Survey

Content: You will see your registration ID displayed on the screen. Each group or virtual
group receives a single registration ID that will not change whether you modify, cancel or
add a new registration. All the contacts associated with the registration will also receive
an email notification of their successful registration.
Select Back to List to complete another registration for the same group or virtual group,
or to register another group for the CMS Web Interface and/or CAHPS for MIPS Survey.
2020 Final Document text:
Section: Submit a New Registration for the CMS Web Interface and/or CAHPS for MIPS
Survey
Content: 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.

Change #30:
Location:
2019 – Page 20
2020 – Page 22
Reason for Change:
Edited for clarity
2019 Final Document text:
Section: Submit a New Registration for the CMS Web Interface and/or CAHPS for MIPS
Survey
Content:
8. In Manage Access, confirm you see a green checkmark next to CMS Web Interface
(or CAHPS for MIPS Survey), indicating your successful registration for your group or
virtual group.
2020 Final Document text:
Section: Submit a New Registration for the CMS Web Interface and/or CAHPS for MIPS
Survey
Content:
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.

Change #31:
Location:
2019 – Page 21
2020 – Page 23
Reason for Change:
Edited for clarity and alignment with current program year dates, deadlines,
links/resources
2019 Final Document text:
Section: Modify Information for an Organization with an Existing Registration for the
CMS Web Interface and/or the CAHPS for MIPS Survey
Content: 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:
o

o

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

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:


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.
2020 Final Document text:
Section: Modify Information for an Organization with an Existing Registration for the
CMS Web Interface and/or the CAHPS for MIPS Survey
Content: You may need to modify your information for any of the following reasons:
•
•
•
•
•

You were automatically registered for the CMS Web Interface, and the Group Size
from your 2018 registration is no longer accurate.
You were automatically registered for the CMS Web Interface, and the
Organization Address from your 2018 registration is no longer accurate.
You were automatically registered for the CMS Web Interface, and the Contact
Information (name, email, and/or phone number) from your 2018 registration is no
longer accurate.
You need to update the Organization Address.
You need to update Contact Information, or change the Contacts associated with
the group’s registration.

You can modify information for a group or virtual group with an existing registration for the
CMS Web Interface and/or CAHPS for MIPS survey for performance period 2019 any time
before the registration period closes on July 1, 2019 at 5:00 pm ET.

Change #32:
Location:
2019 – Page 22
2020 – Page 24
Reason for Change:
Edited for clarity
2019 Final Document text:
Section: Modify Information for an Organization with an Existing Registration for the
CMS Web Interface and/or the CAHPS for MIPS Survey
Content:
1. Complete the steps in Section III (Access the Registration System).
2. To edit the Group Size, select Edit next to Size.
3. Select the correct group size and confirm or cancel the change.
2020 Final Document text:
Section: Modify Information for an Organization with an Existing Registration for the
CMS Web Interface and/or the CAHPS for MIPS Survey
Content:
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.

Change #33:
Location:
2019 – Page 23
2020 – Page 25
Reason for Change:
Edited for clarity and alignment with current program year dates, deadlines,
links/resources
2019 Final Document text:
Section: Modify Information for an Organization with an Existing Registration for the
CMS Web Interface and/or the CAHPS for MIPS Survey
Content:
1. To update Organization or Contact Information, select Show Details below the TIN or
Virtual Group ID information.
2.
3. To update the Organization’s Address, select Edit, which will allow you to update the
address, city, state, and zip code as needed.

2020 Final Document text:
Section: Modify Information for an Organization with an Existing Registration for the
CMS Web Interface and/or the CAHPS for MIPS Survey
Content:
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.

Change #34:
Location:
2019 – Page 24
2020 – Page 26
Reason for Change:
Edited for clarity and alignment with current program year dates, deadlines,
links/resources
2019 Final Document text:
Section: Submit a New Registration for the CMS Web Interface and/or CAHPS for MIPS
Survey
Content:
6. 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
group 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, Email, and Phone Number.
7. To add a new contact, select Add New Contact; you will be prompted to provide the
Contact’s First and Last Name, Email and Phone Number.
2020 Final Document text:
Section: Submit a New Registration for the CMS Web Interface and/or CAHPS for MIPS
Survey
Content:
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, email 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.

Change #35:
Location:
2019 – Page 25
2020 – Page 27
Reason for Change:
Edited for clarity and alignment with current program year dates, deadlines,
links/resources
2019 Final Document text:
Section: View your CMS Web Interface and/or CAHPS for MIPS Survey Registration
Summary
Content:
The registration system will allow you to view information about the CMS Web Interface
and/or CAHPS for MIPS Survey registrations for all the groups and virtual groups for
which you have a Security Official role for their organization. A green checkmark
indicates an existing registration, a yellow semi-circle indicates there is no registration.
Note: Each group and virtual group will receive a single Registration ID to track all
registration activity.
To view your group or virtual group’s registration information, follow the steps in Section
III (Access the Registration System).
2020 Final Document text:
Section: View your CMS Web Interface and/or CAHPS for MIPS Survey Registration
Summary
Content:
The registration system will allow you to view information about the CMS Web Interface
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.
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.

Change #36:
Location:
2019 – Page 25-27
2020 – Page 28-30
Reason for Change:
Edited for clarity and alignment with current program year dates, deadlines,
links/resources
2019 Final Document text:
Section: Cancel Your 2019 Registration for the CMS Web Interface and/or CAHPS for
MIPS Survey
Content:
If your group or virtual group is registered to participate in MIPS utilizing the CMS Web
Interface and/or administering the CAHPS for MIPS survey for the 2019 performance
period, but wishes to cancel the registration, you can log into the registration system and
cancel the registration any time before the registration period closes on July 1, 2019 at
5:00 pm ET.
If you want to re-register the group or virtual group during the registration period after
cancelling your registration, please refer to Section IV (Submit a New Registration) of
this guide.
Note: You will can’t cancel the group or virtual group’s 2019 registration after July 1,
2019 at 5:00 pm ET.
1. Complete the steps in Section III (Access the Registration System).
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 email 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 email with the Registration Identification Number
confirming your registration cancellation.
5. When you return to the list of Connected Practices, you should see that the group
or virtual group is no longer registered for the CMS Web Interface.
Note: If you did not intend to cancel the group or virtual group’s registration, please
follow the guidance in Section IV (Submit a New Registration) to re-register your
group before the registration period closes on July 1, 2019 at 5:00 pm ET.
2020 Final Document text:
Section: Cancel Your 2020 Registration for the CMS Web Interface and/or CAHPS for
MIPS Survey
Content:
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.
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.