Information Collection

2023 > (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 19)

IC 227506 under ICR 202107-0938-013 · OMB 0938-1314.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1314 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10621 (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 19)	Form
CMS-10621 Hardship Exception Application Form Appendix K1 2020 Promoting Interoperability Hardship Exception Application.pdf	Form
CMS-10621 Hardship Exception Application Form Appendix K1 2020 Promoting Interoperability Hardship Exception Application.pdf	Form
CMS-10621 Extreme and Uncontrollable Circumstances Application For Appendix L1 2020 Extreme and Uncontrollable Circumstances Reweighting Application.pdf	Form
CMS-10621 Extreme and Uncontrollable Circumstances Application For Appendix L1 2020 Extreme and Uncontrollable Circumstances Reweighting Application.pdf	Form

IC Title:

2023 > (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 19)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.1375

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10621	Hardship Exception Application Form	Appendix K1 2020 Promoting Interoperability Hardship Exception Application.pdf		Yes	Yes	Fillable Fileable
Form	CMS-10621	Extreme and Uncontrollable Circumstances Application Form	Appendix L1 2020 Extreme and Uncontrollable Circumstances Reweighting Application.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Quality Payment Program (QPP), System No. 09â70â 0539

FR Citation: 83 FR 6587

Number of Respondents: 42,827

Number of Respondents for Small Entity: 30,620

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	42,827	-9,272	52,099
Annual IC Time Burden (Hours)	10,707	-2,318	13,025
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.