Appendix E2 (See Table 28): 2022 Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician...) Crosswalk

All-Payer Clinician Initiated Submission Form
CY 2021 Final versus CY 2022 Final

Burden impact: The changes to this form reflect policies in the CY 2022 Physician Fee
Schedule (PFS) Final Rule for the Quality Payment Program. There are no impacts to burden
as a result of these changes.
*****
Change #1:
Location: Page 1, Line 39
Reason for Change:
Alignment with current year.
CY 2020 Final Rule text:
2020
CY 2021 Final Rule text:
2022
*****
Change #2:
Location: Page 1, Line 42
Reason for Change:
Alignment with current year.
CY 2020 Final Rule text:
December 1, 2020 for the 2020
CY 2021 Final Rule text:
December 1, 2022 for the 2022
*****
Change #3:
Location: Page 2, Line 9
Reason for Change:
Alignment with current year.
CY 2020 Final Rule text:
2019 for the 2020
CY 2021 Final Rule text:
2021 for the 2022

*****
Change #4:
Location: Page 9, Lines 6-9
Reason for Change:
Edited for clarity
CY 2020 Final Rule text:
For performance year 2021 and later, is the total amount that your participating entity
potentially owes or foregoes under the payment arrangement at least at least 5 percent
of the average estimated total revenue of the participating providers or other entities
under the payer in 2021?
CY 2021 Final Rule text:
Is the total amount that your participating entity potentially owes or foregoes under the
payment arrangement at least at least 5 percent of the average estimated total revenue
of the participating providers or other entities under the payer?
*****
Change #5:
Location: Page 13, Line 28
Reason for Change:
Alignment with current year and proposed changes.
CY 2020 Final Rule text:
50
CY 2021 Final Rule text:
75