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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10621 Appendix N1 (See Table 13): 2021 CMS Web Interface and CAHPS for MIPS Registration Guide (for the 2023 MIPS payment year) (Revised)	Form and Instruction	New	Available
Form cms-10621 Appendix L1 (See Table 16): 2021 Extreme and Uncontrollable Circumstances Application Form for the 2023 MIPS payment year (No change)	Form and Instruction	New	Available
Form cms-10621 Appendix K1 (See Table 16): 2021 Hardship Exception Application Form (for the 2023 MIPS payment year) (No change)	Form and Instruction	New	Available
Form cms-10621 Appendix C1 (Table 4): 2022 Qualified Clinical Data Registry (QCDR) Measure Submission Template (Revised, Conversion to Webform)	Form and Instruction	New	Available
Form CMS-10621 Appendix O1 (See Table 26): 2020 Partial QP Election Form (for the 2022 MIPS payment year) (New)	Form and Instruction	New	Available
Form CMS-10621 Appendix M1 (See Table 25): 2022 MVP Candidates: Instructions and Template (Revised)	Form and Instruction	New	Available
Form CMS-10621 Appendix J1 (See Table 24): Improvement Activities Performance Category, 2022 Call for Activities Submission Form (Revised)	Form and Instruction	New	Available
Form CMS-10621 Appendix I1 (See Table 20): Promoting Interoperability Performance Category, 2022 Call for Measures Submission Form (Revised)	Form and Instruction	New	Available
Form CMS-10621 Appendix H1 (See Table 15): 2022 Peer Reviewed Journal Article Requirement Template (Revised)	Form and Instruction	New	Available
Form CMS-10621 Appendix G1 (See Table 15): Measures under Consideration 2021 (for the 2023 performance period), Data Template for Candidate Measures (Revised)	Form and Instruction	New	Available
Form CMS-10621 Appendix F1 (See Table 29): 2022 Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option (Revised)	Form and Instruction	New	Available
Form CMS-10621 Appendix E1 (See Table 28): 2022 Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submissi	Form and Instruction	New	Available
Form CMS-10621 Appendix D1 (See Table 27): 2022 Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form) (Revised)	Form and Instruction	New	Available
Form CMS-10621 Stakeholder Submissions of MIPS Value Pathways (MVP) Candidates: Instructions and Template	Form and Instruction	Removed	Available
Form CMS-10621 Nomination of MVPs (SS-A Table 23)	Form and Instruction	Removed	Repair queued
Form CMS-10621 Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option	Form	Removed	Available
Form CMS-10621 Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 27)	Form	Removed	Repair queued
Form CMS-10621 Measures under Consideration 2019, Data Template for Candidate Measures	Form and Instruction	Removed	Available
Form CMS-10621 Peer Reviewed Journal Article Requirement Template	Form and Instruction	Removed	Repair queued
Form CMS-10621 (Quality Performance Category) Call for Quality Measures (see SS-A Table 15)	Form and Instruction	Removed	Repair queued
Form CMS-10621 Eligible Clinician Initiated Submission Form	Form	Removed	Available
Form CMS-10621 Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 26)	Form	Removed	Repair queued
Form CMS-10621 Promoting Interoperability Performance Category, 2021 Call for Measures Submission Form	Form and Instruction	Removed	Available
Form CMS-10621 (PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 19)	Form and Instruction	Removed	Repair queued
Form CMS-10621 Payer Initiated Submission Form	Form and Instruction	Removed	Available
Form CMS-10621 Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 25)	Form and Instruction	Removed	Repair queued
Form CMS-10621 Improvement Activities Performance Category, 2021 Call for Activities Submission Form	Form	Removed	Available
Form CMS-10621 (Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 22)	Form	Removed	Repair queued
Form CMS-10621 Extreme and Uncontrollable Circumstances Application Form	Form	Removed	Available
Form CMS-10621 Hardship Exception Application Form	Form	Removed	Available
Form CMS-10621 (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)	Form	Removed	Repair queued
Form CMS-10621 2021 Qualified Clinical Data Registry (QCDR) Measure Submission Template	Form	Removed	Available
Form CMS-10621 Stakeholder Submissions of MIPS Value Pathways (MVP) Candidates: Instructions and Template	Form and Instruction	Removed	Repair queued
Form CMS-10621 Nomination of MVPs (SS-A Table 23)	Form and Instruction	Removed	Repair queued
Form CMS-10621 Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option	Form	Removed	Available
Form CMS-10621 Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 27)	Form	Removed	Repair queued
Form CMS-10621 Measures under Consideration 2019, Data Template for Candidate Measures	Form and Instruction	Removed	Available
Form CMS-10621 Peer Reviewed Journal Article Requirement Template	Form and Instruction	Removed	Available
Form CMS-10621 (Quality Performance Category) Call for Quality Measures (see SS-A Table 15)	Form and Instruction	Removed	Repair queued
Form CMS-10621 Eligible Clinician Initiated Submission Form	Form	Removed	Available
Form CMS-10621 Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 26)	Form	Removed	Repair queued
Form CMS-10621 Promoting Interoperability Performance Category, 2021 Call for Measures Submission Form	Form and Instruction	Removed	Repair queued
Form CMS-10621 (PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 19)	Form and Instruction	Removed	Repair queued
Form CMS-10621 Payer Initiated Submission Form	Form and Instruction	Removed	Repair queued
Form CMS-10621 Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 25)	Form and Instruction	Removed	Repair queued
Form CMS-10621 Improvement Activities Performance Category, 2021 Call for Activities Submission Form	Form	Removed	Available
Form CMS-10621 (Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 22)	Form	Removed	Repair queued
Form CMS-10621 Extreme and Uncontrollable Circumstances Application Form	Form	Removed	Available
Form CMS-10621 Hardship Exception Application Form	Form	Removed	Repair queued
Form CMS-10621 (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)	Form	Removed	Repair queued
Form CMS-10621 2021 Qualified Clinical Data Registry (QCDR) Measure Submission Template	Form	Removed	Available
CMS-10621 - Supporting Statement B (CMS-1751-F)_10-28 Clean.docx	Supporting Statement B	Uploaded 2021-12-06	Available
CMS-10621 - Supporting Statement A (CMS-1751-F version 12).docx	Supporting Statement A	Uploaded 2021-12-06	Repair queued
Appendix N2 2022 CMS Web Interface and CAHPS for MIPS Registration Guide Crosswalk.pdf	Supplementary Document	Uploaded 2021-12-06	Repair queued
Appendix C2 2022 Qualified Clinical QCDR Measure Submission Template vs Webform Crosswalk.pdf	Supplementary Document	Uploaded 2021-12-06	Repair queued
Appendix M2 2022 MVP Development Standardized Template Crosswalk.pdf	Supplementary Document	Uploaded 2021-12-06	Repair queued
Appendix J2 2022 IA Call for Activities Crosswalk_PIMMS updated.pdf	Supplementary Document	Uploaded 2021-12-06	Repair queued
Appendix I2 2022 PI Call for Measures Submission Form Crosswalk.pdf	Supplementary Document	Uploaded 2021-12-06	Repair queued
Appendix H2 2022 Peer Reviewed Journal Article Template Crosswalk.pdf	Supplementary Document	Uploaded 2021-12-06	Repair queued
Appendix G2 2021 MUC Data Template Crosswalk.pdf	Supplementary Document	Uploaded 2021-12-06	Repair queued
Appendix F2 2022 All-Payer QP Data Submission Form Crosswalk.pdf	Supplementary Document	Uploaded 2021-12-06	Repair queued
Appendix E2 2022 Clinician Initiated Submission Form Crosswalk.pdf	Supplementary Document	Uploaded 2021-12-06	Repair queued
Appendix D2 2022 Payer Initiated Submission Form Crosswalk.pdf	Supplementary Document	Uploaded 2021-12-06	Repair queued
Appendix B2 2022 Appendix B2 MIPS QCDR Self-Nomination Fact Sheet Crosswalk.pdf	Supplementary Document	Uploaded 2021-12-06	Repair queued
Appendix A2 2022 MIPS Qualified Registry Self-Nomination Fact Sheet Crosswalk.pdf	Supplementary Document	Uploaded 2021-12-06	Repair queued
Comment Responses MIPS PRA _10_28 Clean.docx	Supplementary Document	Uploaded 2021-12-03	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
250664	CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary		New
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Form and Instruction	New	Appendix N1 (See Table 13): 2021 CMS Web Interface and CAHPS for MIPS Registration Guide (for the 2023 MIPS payment year) (Revised)
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Form and Instruction	New	Appendix L1 (See Table 16): 2021 Extreme and Uncontrollable Circumstances Application Form for the 2023 MIPS payment year (No change)
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Form and Instruction	New	Appendix K1 (See Table 16): 2021 Hardship Exception Application Form (for the 2023 MIPS payment year) (No change)
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Form and Instruction	New	Appendix C1 (Table 4): 2022 Qualified Clinical Data Registry (QCDR) Measure Submission Template (Revised, Conversion to Webform)
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Form and Instruction	New	Appendix O1 (See Table 26): 2020 Partial QP Election Form (for the 2022 MIPS payment year) (New)
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Form and Instruction	New	Appendix M1 (See Table 25): 2022 MVP Candidates: Instructions and Template (Revised)
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Form and Instruction	New	Appendix J1 (See Table 24): Improvement Activities Performance Category, 2022 Call for Activities Submission Form (Revised)
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Form and Instruction	New	Appendix I1 (See Table 20): Promoting Interoperability Performance Category, 2022 Call for Measures Submission Form (Revised)
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Form and Instruction	New	Appendix H1 (See Table 15): 2022 Peer Reviewed Journal Article Requirement Template (Revised)
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Form and Instruction	New	Appendix G1 (See Table 15): Measures under Consideration 2021 (for the 2023 performance period), Data Template for Candidate Measures (Revised)
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Form and Instruction	New	Appendix F1 (See Table 29): 2022 Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option (Revised)
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Form and Instruction	New	Appendix E1 (See Table 28): 2022 Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submissi
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Form and Instruction	New	Appendix D1 (See Table 27): 2022 Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form) (Revised)
250662	CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	Other-Appendix A1 (See Table 3): 2022 Qualified Registry Fact Sh	New
245893	2022 >> Open Authorization Credentialing and Token Request Process (SS-A Table 5)		Removed
245892	2022 >> Nomination of MVPs (SS-A Table 23)	Form and Instruction	Removed	Stakeholder Submissions of MIPS Value Pathways (MVP) Candidates: Instructions and Template
245892	Nomination of MVPs (SS-A Table 23)	Form and Instruction	Removed
245891	2022 >> Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 27)	Form	Removed	Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option
245891	Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 27)	Form	Removed
245886	2022 >> QPP Identity Management Application Process (see SS-A Table 9)		Removed
245885	2022 >> (Quality Performance Category) Call for Quality Measures (see SS-A Table 15)	Form and Instruction	Removed	Measures under Consideration 2019, Data Template for Candidate Measures
245885	2022 >> (Quality Performance Category) Call for Quality Measures (see SS-A Table 15)	Form and Instruction	Removed	Peer Reviewed Journal Article Requirement Template
245885	(Quality Performance Category) Call for Quality Measures (see SS-A Table 15)	Form and Instruction	Removed
245884	2022 >> Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 26)	Form	Removed	Eligible Clinician Initiated Submission Form
245884	Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 26)	Form	Removed
245883	2022 >> (PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 19)	Form and Instruction	Removed	Promoting Interoperability Performance Category, 2021 Call for Measures Submission Form
245883	(PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 19)	Form and Instruction	Removed
245882	2022 >> (Physician Compare) Opt Out for Voluntary Participants (see SS-A Table 28)		Removed
245881	2022 >> Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 25)	Form and Instruction	Removed	Payer Initiated Submission Form
245881	Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 25)	Form and Instruction	Removed
245880	2022 >> (Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 22)	Form	Removed	Improvement Activities Performance Category, 2021 Call for Activities Submission Form
245880	(Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 22)	Form	Removed
245879	2022 >> (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)	Form	Removed	Extreme and Uncontrollable Circumstances Application Form
245879	2022 >> (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)	Form	Removed	Hardship Exception Application Form
245879	(PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)	Form	Removed
245877	2022 >> Partial Qualifying APM Participant (QP) Election (see SS-A Table 24)		Removed
245875	2022 >> (Improvement Activities Performance Category) Data Submission (see SS-A Table 21)		Removed
245874	2022 >> (PI Performance Category) Data Submission (see SS-A Table 18)		Removed
245873	2022 >> Self-nomination: QCDR and Qualified Registry (see SS-A Tables 3 and 4)	Form	Removed	2021 Qualified Clinical Data Registry (QCDR) Measure Submission Template
245873	2022 >> Self-nomination: QCDR and Qualified Registry (see SS-A Tables 3 and 4)	Instruction	Removed
245870	2022 >> (Quality Performance Category) eCQM Collection Type (see SS-A Table 12)		Removed
245869	2022 >> (Quality Performance Category) QCDR/MIPS CQM Collection Type (see SS-A Table 11)		Removed
245867	2022 >> (Quality Performance Category) Claims Collection Type (see Table SS-A 10)		Removed
245240	2021 > Open Authorization Credentialing and Token Request Process (SS-A Table 5)		Removed
245229	2021 > Nomination of MVPs (SS-A Table 23)	Form and Instruction	Removed	Stakeholder Submissions of MIPS Value Pathways (MVP) Candidates: Instructions and Template
245229	Nomination of MVPs (SS-A Table 23)	Form and Instruction	Removed
233582	2021 > Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 27)	Form	Removed	Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option
233582	Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 27)	Form	Removed
233581	2021 > QPP Identity Management Application Process (see SS-A Table 9)		Removed
229086	2021 > (Quality Performance Category) Call for Quality Measures (see SS-A Table 15)	Form and Instruction	Removed	Measures under Consideration 2019, Data Template for Candidate Measures
229086	2021 > (Quality Performance Category) Call for Quality Measures (see SS-A Table 15)	Form and Instruction	Removed	Peer Reviewed Journal Article Requirement Template
229086	(Quality Performance Category) Call for Quality Measures (see SS-A Table 15)	Form and Instruction	Removed
229075	2021 > Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 26)	Form	Removed	Eligible Clinician Initiated Submission Form
229075	Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 26)	Form	Removed
229074	2021 > (PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 19)	Form and Instruction	Removed	Promoting Interoperability Performance Category, 2021 Call for Measures Submission Form
229074	(PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 19)	Form and Instruction	Removed
227511	2021 > (Physician Compare) Opt Out for Voluntary Participants (see SS-A Table 28)		Removed
227509	2021 > Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 25)	Form and Instruction	Removed	Payer Initiated Submission Form
227509	Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 25)	Form and Instruction	Removed
227507	2021 > (Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 22)	Form	Removed	Improvement Activities Performance Category, 2021 Call for Activities Submission Form
227507	(Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 22)	Form	Removed
227506	2021 > (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)	Form	Removed	Extreme and Uncontrollable Circumstances Application Form
227506	2021 > (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)	Form	Removed	Hardship Exception Application Form
227506	(PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)	Form	Removed
227505	2021 > (Quality Performance Category) Registration and Enrollment for CMS Web Interface (see SS-A Table 14)	Instruction	Removed
221786	2021 > Partial Qualifying APM Participant (QP) Election (see SS-A Table 24)		Removed
221785	2021 > (Improvement Activities Performance Category) Data Submission (see SS-A Table 21)		Removed
221784	2021 > (PI Performance Category) Data Submission (see SS-A Table 18)		Removed
221782	2021 > Self-nomination: QCDR and Qualified Registry (see SS-A Tables 3 and 4)	Form	Removed	2021 Qualified Clinical Data Registry (QCDR) Measure Submission Template
221782	2021 > Self-nomination: QCDR and Qualified Registry (see SS-A Tables 3 and 4)	Instruction	Removed
221781	2021 > (Quality Performance Category) CMS Web Interface Submission Type (see SS-A Table 13)		Removed
221780	2021 > (Quality Performance Category) eCQM Collection Type (see SS-A Table 12)		Removed
221779	2021 > (Quality Performance Category) QCDR/MIPS CQM Collection Type (see SS-A Table 11)		Removed
221777	2021 > (Quality Performance Category) Claims Collection Type (see Table SS-A 10)		Removed

ICR Details

OMB Control No: 0938-1314	ICR Reference No: 202111-0938-001
Status: Historical Active	Previous ICR Reference No: 202101-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Quality Payment Program/Merit-Based Incentive Payment System (MIPS) (CMS-10621)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/10/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/06/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2025	36 Months From Approved	01/31/2022
Responses	633,021	0	654,162
Time Burden (Hours)	2,825,380	0	2,957,004
Cost Burden (Dollars)	0	0	0

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Abstract: Section 1848(q) of the Social Security Act, as amended by section 101 of the Medicare Access and CHIP Reauthorization Act of 2015, authorizes the establishment of a Merit-based Incentive Payment System (MIPS) for eligible clinicians. Beginning in CY 2017, eligible clinicians are required to collect and submit data on four performance categories to CMS (quality, cost, advancing care information and improvement activities). This program replaces and consolidates portions of the PQRS, Value-based Modifier, and the Medicare EHR Incentive Program. The Act also establishes a second track, Advanced Alternative Payment Models (APMs) for clinicians to participate in instead of MIPS.

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Authorizing Statute(s): US Code: 42 USC 1395w-4 Name of Law: Medicare Access and CHIP Reauthorization Act of 2014
  

Citations for New Statutory Requirements: US Code: 42 USC 1395w-4 Name of Law: Medicare Access and CHIP Reauthorization Act of 2014

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AU42	Final or interim final rulemaking	86 FR 64996	11/19/2021

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 39104	07/23/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 64996	11/19/2021
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
2021 > (Improvement Activities Performance Category) Data Submission (see SS-A Table 21)
2021 > (Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 22)	CMS-10621	Improvement Activities Performance Category, 2021 Call for Activities Submission Form
2021 > (PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 19)	CMS-10621	Promoting Interoperability Performance Category, 2021 Call for Measures Submission Form
2021 > (PI Performance Category) Data Submission (see SS-A Table 18)
2021 > (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)	CMS-10621, CMS-10621	Hardship Exception Application Form ,   Extreme and Uncontrollable Circumstances Application Form
2021 > (Physician Compare) Opt Out for Voluntary Participants (see SS-A Table 28)
2021 > (Quality Performance Category) CMS Web Interface Submission Type (see SS-A Table 13)
2021 > (Quality Performance Category) Call for Quality Measures (see SS-A Table 15)	CMS-10621, CMS-10621	Peer Reviewed Journal Article Requirement Template ,   Measures under Consideration 2019, Data Template for Candidate Measures
2021 > (Quality Performance Category) Claims Collection Type (see Table SS-A 10)
2021 > (Quality Performance Category) QCDR/MIPS CQM Collection Type (see SS-A Table 11)
2021 > (Quality Performance Category) Registration and Enrollment for CMS Web Interface (see SS-A Table 14)
2021 > (Quality Performance Category) eCQM Collection Type (see SS-A Table 12)
2021 > Nomination of MVPs (SS-A Table 23)	CMS-10621	Stakeholder Submissions of MIPS Value Pathways (MVP) Candidates: Instructions and Template
2021 > Open Authorization Credentialing and Token Request Process (SS-A Table 5)
2021 > Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 26)	CMS-10621	Eligible Clinician Initiated Submission Form
2021 > Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 25)	CMS-10621	Payer Initiated Submission Form
2021 > Partial Qualifying APM Participant (QP) Election (see SS-A Table 24)
2021 > QPP Identity Management Application Process (see SS-A Table 9)
2021 > Self-nomination: QCDR and Qualified Registry (see SS-A Tables 3 and 4)	CMS-10621	2021 Qualified Clinical Data Registry (QCDR) Measure Submission Template
2021 > Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 27)	CMS-10621	Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option
2022 >> (Improvement Activities Performance Category) Data Submission (see SS-A Table 21)
2022 >> (Improvement Activities Performance Category) Nomination of Improvement Activities (see SS-A Table 22)	CMS-10621	Improvement Activities Performance Category, 2021 Call for Activities Submission Form
2022 >> (PI Performance Category) Call for Promoting Interoperability Measures (see SS-A Table 19)	CMS-10621	Promoting Interoperability Performance Category, 2021 Call for Measures Submission Form
2022 >> (PI Performance Category) Data Submission (see SS-A Table 18)
2022 >> (PI Performance Category) Reweighting Applications for Promoting Interoperability and Other Performance Categories (see SS-A Table 16)	CMS-10621, CMS-10621	Hardship Exception Application Form ,   Extreme and Uncontrollable Circumstances Application Form
2022 >> (Physician Compare) Opt Out for Voluntary Participants (see SS-A Table 28)
2022 >> (Quality Performance Category) Call for Quality Measures (see SS-A Table 15)	CMS-10621, CMS-10621	Peer Reviewed Journal Article Requirement Template ,   Measures under Consideration 2019, Data Template for Candidate Measures
2022 >> (Quality Performance Category) Claims Collection Type (see Table SS-A 10)
2022 >> (Quality Performance Category) QCDR/MIPS CQM Collection Type (see SS-A Table 11)
2022 >> (Quality Performance Category) eCQM Collection Type (see SS-A Table 12)
2022 >> Nomination of MVPs (SS-A Table 23)	CMS-10621	Stakeholder Submissions of MIPS Value Pathways (MVP) Candidates: Instructions and Template
2022 >> Open Authorization Credentialing and Token Request Process (SS-A Table 5)
2022 >> Other Payer Advanced APM Identification: Clinician Initiated Process (see SS-A Table 26)	CMS-10621	Eligible Clinician Initiated Submission Form
2022 >> Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 25)	CMS-10621	Payer Initiated Submission Form
2022 >> Partial Qualifying APM Participant (QP) Election (see SS-A Table 24)
2022 >> QPP Identity Management Application Process (see SS-A Table 9)
2022 >> Self-nomination: QCDR and Qualified Registry (see SS-A Tables 3 and 4)	CMS-10621	2021 Qualified Clinical Data Registry (QCDR) Measure Submission Template
2022 >> Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 27)	CMS-10621	Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option
CY 2022 Performance Period/2024 MIPS Payment Year Burden Summary	cms-10621, cms-10621, cms-10621, CMS-10621, CMS-10621, CMS-10621, CMS-10621, CMS-10621, CMS-10621, CMS-10621, CMS-10621, CMS-10621, CMS-10621	Appendix D1 (See Table 27): 2022 Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form) (Revised) ,   Appendix E1 (See Table 28): 2022 Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submissi ,   Appendix F1 (See Table 29): 2022 Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option (Revised) ,   Appendix G1 (See Table 15): Measures under Consideration 2021 (for the 2023 performance period), Data Template for Candidate Measures (Revised) ,   Appendix H1 (See Table 15): 2022 Peer Reviewed Journal Article Requirement Template (Revised) ,   Appendix I1 (See Table 20): Promoting Interoperability Performance Category, 2022 Call for Measures Submission Form (Revised) ,   Appendix J1 (See Table 24): Improvement Activities Performance Category, 2022 Call for Activities Submission Form (Revised) ,   Appendix M1 (See Table 25): 2022 MVP Candidates: Instructions and Template (Revised) ,   Appendix O1 (See Table 26): 2020 Partial QP Election Form (for the 2022 MIPS payment year) (New) ,   Appendix C1 (Table 4): 2022 Qualified Clinical Data Registry (QCDR) Measure Submission Template (Revised, Conversion to Webform) ,   Appendix K1 (See Table 16): 2021 Hardship Exception Application Form (for the 2023 MIPS payment year) (No change) ,   Appendix L1 (See Table 16): 2021 Extreme and Uncontrollable Circumstances Application Form for the 2023 MIPS payment year (No change) ,   Appendix N1 (See Table 13): 2021 CMS Web Interface and CAHPS for MIPS Registration Guide (for the 2023 MIPS payment year) (Revised)
CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary

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ICR Summary of Burden

table that charts list of burden

	Total Approved	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	633,021	654,162	336,742	-361,096	3,213	0
Annual Time Burden (Hours)	2,825,380	2,957,004	1,393,824	-1,569,428	43,980	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The changes in this CY 2022 collection of information request are associated with our November 19, 2021 final rule (CMS-1751-F, RIN 0938-AU42). Overall, we estimate a decrease of 21,141 responses, 131,624 hours, and $9,066,223.

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Annual Cost to Federal Government: $176

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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.     Yes

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.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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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: 12/06/2021

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