2022 >> (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 19)

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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

IC Title:	2022 >> (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:

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. 09–70– 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 %

	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

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.