2022 >> Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 31)

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⚠️ Notice: This information collection may be referencing outdated material.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 Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 31) Form
CMS-10621 Appendix E1 2022 Submission Form for Eligible Clinician Appendix E1 2022 Clinician Initiated Submission Form.pdf Form
CMS-10621 Appendix E1 2022 Submission Form for Eligible Clinician Appendix E1 2022 Clinician Initiated Submission Form.pdf Form
Appendix E2 2022 Clinician Initiated Submission Form Crosswalk.pdf CROSSWALK Appendix E2) Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payme IC Document
Appendix E2 2022 Clinician Initiated Submission Form Crosswalk.pdf CROSSWALK Appendix E2) Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payme IC Document

Information Collection (IC) Details

IC Title:	2022 >> Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 31)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.1445

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10621	Appendix E1 2022 Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submission Fo	Appendix E1 2022 Clinician Initiated Submission Form.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: 15	Number of Respondents for Small Entity: 15

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	15	-135	150
Annual IC Time Burden (Hours)	150	-1,350	1,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
CROSSWALK Appendix E2) Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Sub	Appendix E2 2022 Clinician Initiated Submission Form Crosswalk.pdf	09/01/2021

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