Form CMS-10621 2021 CMS Web Interface and CAHPS for MIPS Registration G

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

Appendix N1 2022 CMS Web Interface and CAHPS for MIPS Registration Guide

2022 >> Quality Data Submission via the CMS Web Interface (SS-A Table 16)

OMB: 0938-1314

⚠️ Notice: This form may be outdated.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

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2021 Registration Guide for the CMS Web
Interface and the CAHPS for MIPS Survey

Table of Contents
Section

Page Number
2

Introduction

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

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

VI.

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

VII.

Cancel Your 2021 Registration for the CMS Web Interface
and/or the CAHPS for MIPS Survey

I. Introduction
This guide provides information and instructions on the CMS Web Interface and the Consumer
Assessment of Healthcare Providers and Systems (CAHPS) for Merit-based Incentive Payment
System (MIPS) Survey registration process for the 2021 performance period.
For additional information, visit the following resources:
•

The 2021 CMS Web Interface Quick Start Guide (PDF) for more information about quality
data submissions through the CMS Web Interface.

•

The 2021 CAHPS for MIPS Survey Overview Fact Sheet (PDF) for more information about
administering the CAHPS for MIPS Survey.

Please visit the Quality Payment Program (QPP) website for additional information.

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 the QPP.
Registration opens on Thursday, April 1, 2021 at 10 a.m. ET and closes on Wednesday, June
30, 2021 at 8 p.m. ET.
To complete your organization’s registration, you need a HCQIS Access Roles and Profile
(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 eligible 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. Only virtual groups that CMS
approves and identifies as official virtual groups can participate in MIPS as a virtual group
for the 2021 performance year.

•

Alternative Payment Model (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, TIN, and NPI for each participating eligible clinician.

Who can register for the CMS Web Interface?
CMS Web Interface registration is open to groups, virtual groups, and APM Entities that have 25
or more clinicians and are meeting the quality performance category reporting requirements
under traditional MIPS.
•

Groups and virtual groups that submitted quality data through the CMS Web Interface for
the 2020 performance period are automatically registered for the CMS Web Interface for
the 2021 performance period.

Only Shared Savings Program Accountable Care Organizations (ACOs) can use the CMS Web
Interface to meet reporting requirements for the APM Performance Pathway (APP).
•

Shared Savings Program ACOs are automatically registered for the CMS Web
Interface. Shared Savings Program ACOs are required to meet reporting requirements
under the APP but aren’t required to report quality data through the CMS Web Interface.
Please review the 2021 APM Performance Pathway Quick Start Guide (PDF) or 2021
APM Performance Pathway (APP) for MIPS APM Participant Fact Sheet (PDF) for more
details.

Who can register for the CAHPS for MIPS Survey?
CAHPS for MIPS Survey registration is open to groups, virtual groups, and APM Entities with 2
or more eligible clinicians.
•

The CAHPS for MIPS Survey is a required measure for groups and APM Entities
reporting through the APP.

•

The CAHPS for MIPS Survey is an optional
measure for groups, virtual groups, and APM Entities
reporting through traditional MIPS. In traditional MIPS,
the CAHPS for MIPS Survey can be reported as 1 of the
6 required quality measures and can be attested to as
an improvement activity.

Advance registration is required for any group, virtual group, or
APM Entity that intends to administer the CAHPS for MIPS
Survey, except for Shared Savings Program ACOs.
•

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.

NOTE: Because Shared Savings Program ACOs are required to report through the APP,
they’re automatically registered for the CAHPS for MIPS Survey.

Do we have to submit data through the CMS Web Interface if we’re registered?
No, registered organizations don’t 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)) to submit quality data.
However, organizations that don’t plan to submit quality data through the CMS Web Interface
are strongly encouraged to cancel their registration by 8 p.m. ET on June 30, 2021.

If organizations don’t cancel their registration before the deadline, they can still
submit quality data through other submission types. Is it possible that my
organization won’t be able to report quality measures 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 zero 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 won’t be able to submit quality data through the CMS Web Interface.
If an organization doesn’t have any Medicare patients assigned for any of the CMS Web
Interface measures, the following will occur:
•

We’ll notify the organizations that they can’t submit quality data through the CMS Web
Interface. We anticipate notifications will be sent in the fall 2021.

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., electronic clinical quality measures
(eCQMs) (ZIP) or MIPS clinical quality measures (MIPS CQMs) (ZIP)).

Is it possible we won’t be able to administer the CAHPS for MIPS Survey?
For the 2021 performance period, the CAHPS for MIPS Survey continues to be optional for
organizations meeting reporting requirements under traditional MIPS.
For organizations that are registered to administer the CAHPS for MIPS Survey, we conduct an
assignment and sampling methodology process. Groups, virtual groups, and APM Entities must
meet minimum patient sampling requirements to administer the 2021 CAHPS for MIPS Survey.
If an organization doesn’t meet the minimum patient sampling requirements for the CAHPS for
MIPS Survey, we’ll notify organizations indicating that they won’t be able to administer the
CAHPS for MIPS Survey. We anticipate notifications will be sent in the fall 2021.

Organizations that don’t meet minimum patient sampling requirements:
•

Won’t be able to attest to Participation in CAHPS or Other Supplemental Questionnaire
(IA_PSPA_11) and must select a different activity for the improvement activities
performance category.

•

Won’t 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
organizations are not submitting quality data through the CMS Web Interface.

•

Shared Savings Program ACOs are required to report quality via the APP. ACOs that
don’t meet the minimum patient sampling requirement for the CAHPS for MIPS Survey
will receive a denominator reduction.

II. Get Started
Obtain Access
A representative of the organization will need an account that allows the representative to sign
in to QPP and have the Security Official role for the organization to submit, modify, or cancel a
registration.
Start the account
• If you’re a returning user, sign in with your existing QPP account
creation process
credentials.
now to avoid any
• If you’re a new user, you must create an account before you can
delays in
request Security Official access to your organization by signing in
obtaining an
to QPP.
account and a role
with your
Review the below sections of the QPP Access User Guide (ZIP) for
organization. The
instructions to create an account and/or request the Security Official role
registration period
for your organization.
closes on June
• Register for a HARP Account provides information about
30, 2021 at 8 p.m.
creating a new HARP account.
ET.
•

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

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 QPP 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, if applicable.
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 organization:
•

Organization Information: Organization Name and Mailing Address.

•

Contact Information: First Name, Last Name, Phone Number, and Email.
o

Note: You must provide complete information for at least one contact to submit
your registration; all contacts will be notified by email 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).

III. Access the CMS Web Interface and/or the CAHPS for MIPS Survey
Registration System
You’ll be able to access the registration system between April 1, 2021 (10 a.m. ET) and June
30, 2021 (8 p.m. ET) by signing in to the QPP.
Signing in 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 QPP and click Sign In in the upper right-hand corner.
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’ll be prompted to provide a security code from your twofactor authentication).

3. Complete the Two-Factor Authentication
If this is your first time signing in, you’ll be prompted to set up two-factor authentication
which will be completed in your HARP account. You’ll 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’ll 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 the 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 don’t have the
required Security Official role in for any connected organization(s).
This role is necessary to submit, modify, or cancel a registration.
Review the Connect to an Organization section in the QPP
Access User Guide (ZIP) 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’ll be taken to the main registration page where you’ll see
a list of organizations for which you have a Security Official role.

Follow the steps below whether you’re 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 (ZIP) 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’ll need to complete any required organization and contact
information. You’ll see limited organization and contact information populated.
Select Edit next to the organization to complete any missing required information.
Click the Register button to submit your registration.

4. Review Organization Information
Review the Organization Information that is pre-populated for your group, virtual
group, or APM Entity and update as necessary.
A green checkmark will appear after you enter each piece of required information. Once
you’ve entered all required information, click the Update button.

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 can’t be edited.
5.

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 email
address and phone number, and then click the Update button. (Please note - you can add
additional contacts.)

•

If you shouldn’t be a contact for the organization’s registration, update the first and last
name, add the appropriate contact’s email address and phone number, and then select
Update.

7. Add New Contact
Add an additional contact by selecting Add New, where you’ll be prompted to provide first and
last name, email address, and phone number. Otherwise, click the Register button. (You can
add additional contacts at any point during the registration period.)

8. Congratulations, you have successfully registered!
You’ll see your registration identification number displayed on the screen. Each
organization receives a single registration identification number that won’t change whether you
modify, cancel, or add a new registration. All of the contacts associated with the registration
will also receive an email notification of the successful registration.
Click the Back to List button 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 you’ve
successfully registered 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’ll 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 2021 performance period, you
may do so at any time during the registration period between April 1, 2021 at 10 a.m. ET and
June 30, 2021 at 8 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

o
•

The Organization Size from your registration is no longer accurate.
The Organization Address from your 2020 registration is no longer accurate.
The Contact Information (name, email address, and/or phone number) from your
2020 registration is no longer accurate.

You registered for the CMS Web Interface between April 1, 2021 and June 30, 2021 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’re 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’s at least one contact for a registration. If your
organization only has one contact identified and the contact needs to be changed, you’ll 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’ll 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 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 there is an existing registration, and a yellow semi-circle indicates
there’s no registration.

In the below screenshot, Better Business Health is registered for the CMS Web Interface, but
not registered to administer the CAHPS for MIPS Survey.
Select Show Details 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.
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

VII. Cancel Your 2021 Registration for the CMS Web Interface and/or
the CAHPS for MIPS Survey
If your organization is registered to participate in MIPS using the CMS Web Interface and/or
administering the CAHPS for MIPS Survey for the 2021 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, 2021 at 8p.m. ET.
If you want to re-register the organization during the 2021 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.
Select Cancel Registration under the appropriate registration.

2. Once you select Cancel Registration, you’ll be required to click Continue to cancel your
registration or if you change your mind, click Cancel.

3. You have successfully cancelled your registration. Record the registration identification
number provided in the email notification for your records.
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

If you need to contact QPP 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.
4. 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 didn’t 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 2021 registration period closes on June 30, 2021 at 8 p.m. ET.
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File Type	application/pdf
File Title	2021 Registration Guide for the CMS Web Interface and the CAHPS for MIPS Survey
Author	CMS
File Modified	2021-07-13
File Created	2021-07-13