Forms and Documents

Document Name	Status
Form CMS-10621 Nomination of MVPs (SS-A Table 23) Form and Instruction	Removed
Form CMS-10621 Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 27) Form	Removed
Form CMS-10621 (Quality Performance Category) Call for Quality Measures (see SS-A Table 15) Form and Instruction	Removed
Form CMS-10621 Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 26) Form	Removed
Form CMS-10621 (PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 19) Form and Instruction	Removed
Form CMS-10621 Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 25) Form and Instruction	Removed
Form CMS-10621 (Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 22) Form	Removed
Form CMS-10621 (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16) Form	Removed
Form CMS-10621 Nomination of MVPs (SS-A Table 23) Form and Instruction	Removed
Form CMS-10621 Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 27) Form	Removed
Form CMS-10621 (Quality Performance Category) Call for Quality Measures (see SS-A Table 15) Form and Instruction	Removed
Form CMS-10621 Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 26) Form	Removed
Form CMS-10621 (PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 19) Form and Instruction	Removed
Form CMS-10621 Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 25) Form and Instruction	Removed
Form CMS-10621 (Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 22) Form	Removed
Form CMS-10621 (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16) Form	Removed
CMS-10621 - Supporting Statement B (CMS-1751-F)_10-28 Clean.docx Supporting Statement B	2021-12-06
CMS-10621 - Supporting Statement A (CMS-1751-F version 12).docx Supporting Statement A	2021-12-06
Appendix N2 2022 CMS Web Interface and CAHPS for MIPS Registration Guide Crosswalk.pdf Supplementary Document	2021-12-06
Appendix C2 2022 Qualified Clinical QCDR Measure Submission Template vs Webform Crosswalk.pdf Supplementary Document	2021-12-06
Appendix M2 2022 MVP Development Standardized Template Crosswalk.pdf Supplementary Document	2021-12-06
Appendix J2 2022 IA Call for Activities Crosswalk_PIMMS updated.pdf Supplementary Document	2021-12-06
Appendix I2 2022 PI Call for Measures Submission Form Crosswalk.pdf Supplementary Document	2021-12-06
Appendix H2 2022 Peer Reviewed Journal Article Template Crosswalk.pdf Supplementary Document	2021-12-06
Appendix G2 2021 MUC Data Template Crosswalk.pdf Supplementary Document	2021-12-06
Appendix F2 2022 All-Payer QP Data Submission Form Crosswalk.pdf Supplementary Document	2021-12-06
Appendix E2 2022 Clinician Initiated Submission Form Crosswalk.pdf Supplementary Document	2021-12-06
Appendix D2 2022 Payer Initiated Submission Form Crosswalk.pdf Supplementary Document	2021-12-06
Appendix B2 2022 Appendix B2 MIPS QCDR Self-Nomination Fact Sheet Crosswalk.pdf Supplementary Document	2021-12-06
Appendix A2 2022 MIPS Qualified Registry Self-Nomination Fact Sheet Crosswalk.pdf Supplementary Document	2021-12-06
Comment Responses MIPS PRA _10_28 Clean.docx Supplementary Document	2021-12-03

IC Document Collections

IC ID	Document Title	Status
250664	CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	New
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary Other-Appendix A1 (See Table 3): 2022 Qualified Registry Fact Sh	New
245893	Open Authorization Credentialing and Token Request Process (SS-A Table 5)	Removed
245892	Nomination of MVPs (SS-A Table 23) Form and Instruction	Removed
245891	Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 27) Form	Removed
245886	QPP Identity Management Application Process (see SS-A Table 9)	Removed
245885	(Quality Performance Category) Call for Quality Measures (see SS-A Table 15) Form and Instruction	Removed
245884	Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 26) Form	Removed
245883	(PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 19) Form and Instruction	Removed
245882	(Physician Compare) Opt Out for Voluntary Participants (see SS-A Table 28)	Removed
245881	Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 25) Form and Instruction	Removed
245880	(Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 22) Form	Removed
245879	(PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16) Form	Removed
245877	Partial Qualifying APM Participant (QP) Election (see SS-A Table 24)	Removed
245875	(Improvement Activities Performance Category) Data Submission (see SS-A Table 21)	Removed
245874	(PI Performance Category) Data Submission (see SS-A Table 18)	Removed
245873	Self-nomination: QCDR and Qualified Registry (see SS-A Tables 3 and 4) Instruction	Removed
245870	(Quality Performance Category) eCQM Collection Type (see SS-A Table 12)	Removed
245869	(Quality Performance Category) QCDR/MIPS CQM Collection Type (see SS-A Table 11)	Removed
245867	(Quality Performance Category) Claims Collection Type (see Table SS-A 10)	Removed
245240	Open Authorization Credentialing and Token Request Process (SS-A Table 5)	Removed
245229	Nomination of MVPs (SS-A Table 23) Form and Instruction	Removed
233582	Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 27) Form	Removed
233581	QPP Identity Management Application Process (see SS-A Table 9)	Removed
229086	(Quality Performance Category) Call for Quality Measures (see SS-A Table 15) Form and Instruction	Removed
229075	Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 26) Form	Removed
229074	(PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 19) Form and Instruction	Removed
227511	(Physician Compare) Opt Out for Voluntary Participants (see SS-A Table 28)	Removed
227509	Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 25) Form and Instruction	Removed
227507	(Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 22) Form	Removed
227506	(PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16) Form	Removed
227505	(Quality Performance Category) Registration and Enrollment for CMS Web Interface (see SS-A Table 14) Instruction	Removed
221786	Partial Qualifying APM Participant (QP) Election (see SS-A Table 24)	Removed
221785	(Improvement Activities Performance Category) Data Submission (see SS-A Table 21)	Removed
221784	(PI Performance Category) Data Submission (see SS-A Table 18)	Removed
221782	Self-nomination: QCDR and Qualified Registry (see SS-A Tables 3 and 4) Instruction	Removed
221781	(Quality Performance Category) CMS Web Interface Submission Type (see SS-A Table 13)	Removed
221780	(Quality Performance Category) eCQM Collection Type (see SS-A Table 12)	Removed
221779	(Quality Performance Category) QCDR/MIPS CQM Collection Type (see SS-A Table 11)	Removed
221777	(Quality Performance Category) Claims Collection Type (see Table SS-A 10)	Removed

ICR Details

OMB Control No:	ICR Reference No:
Status:	Previous ICR Reference No:
Agency/Subagency:	Agency Tracking No:
Title:
Type of Information Collection:	Common Form ICR:
Type of Review Request:	Date Received in OIRA:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract:

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR?

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Number of Information Collection (IC) in this ICR: 0

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ICR Summary of Burden

	Total	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	0	0	0	0	0	0
Annual Time Burden (Hours)	0	0	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion:

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion:

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government:

Does this IC contain surveys, censuses, or employ statistical methods?

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.    

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.    

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?

Is this ICR related to the Pandemic Response?

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Common Form ICR: 

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date:

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