Form CMS-10394 Application

PAPER-BASED QE REAPPLICATION FORM
The time required to complete this information collection is estimated to average 120 hours per response,
including the time to review instructions, search existing data resources, gather the needed data, and
complete and review the information collection.
Instructions
Submit the completed QE reapplication form and supporting documents electronically to:
[email protected]. Submit any questions to: [email protected].

Date
Reapplication
Submitted

Department of Health & Human Services
Centers for Medicare & Medicaid Services

Date
Reapplication
Received by CMS

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Section 1: General Information
Instructions: Please input the information for the QE. The listed QE should be the lead applicant.
Subcontractors or partners for this effort should be listed in the Member Organizations field.
Applicant’s Trade Name/DBA
Type of Applicant
Profit Organization
Non-Profit Organization
Other (describe)
Applicant’s Employer ID Number
Name(s) of Contractor(s) or Member
Organization(s)
(Contact [email protected] to
obtain further instructions on submitting the
required contractor or member organization
information)
Data Recipient’s Name
Data Requested
Regional (specify States)
National

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Section 2: Mailing Address
Instructions: The mailing address should be an address where mail correspondence about the
reapplication or program can be delivered.
Street Mailing Address __________________________________________________________
Suite/Mail Stop ________________________________________________________________
City _____________________________________ State ____________ ZIP Code ___________
Phone _______________________________________ Fax _____________________________
Website ______________________________________________________________________

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Section 3: Contact Information
Chief Executive Officer (or other equivalent executive)
Instructions: Please provide the contact information for the CEO, or equivalent executive, who has the
authority to oversee the entity’s reapplication and QECP responsibilities.
Prefix _______ First Name___________________________________________ Middle Initial ______
Last Name________________________________________________ Degree _________________
E-mail Address _________________________________________________________________
Street Mailing Address ___________________________________________________________
Suite/Mail Stop ________________________________________________________________
City _____________________________________ State ____________ ZIP Code ___________
Phone _______________________________________ Fax _____________________________

Point of Contact for Reapplication
Instructions: Please provide the contact information for the individual who will be the primary contact
for day-to-day reapplication and program correspondence.
Prefix _______ First Name______________________________________________ Middle Initial ______
Last Name_________________________________________________ Degree ____________________
E-mail Address _________________________________________________________________
Street Mailing Address ___________________________________________________________
Suite/Mail Stop _________________________________________________________________
City _____________________________________ State ____________ ZIP Code ___________
Phone _______________________________________ Fax _____________________________

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Section 4: Standards

Instructions: Please respond to the questions for each element by checking the appropriate box (i.e.,
Yes, No, Not Applicable, etc.). When required, please provide explanations in the box labeled “QE
Explanation,” using plain language.
For certain elements, qualified entities are required to submit supporting documentation to support
their responses for the purpose of the reapplication minimum requirements review and assessment.
Please list the name of the supporting document, its relevance to the element, and the pages within the
document that demonstrate such relevance. Please refer to the QECP Program Guide for complete
program information, and specifically, Section 5.2: Reapplication QE Program Requirements.

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Element 1.1: Identify changes to the QE’s organization
Question 1: Does your organization intend to continue to contract with the following
organization(s) to fulfill the QECP requirements?
List of current contractors or member organizations:
(The QE’s QECP Program manager pre-fills this list)



Yes
No (Provide explanation below, and submit an updated QECP Letter of
Commitment, including Attachments A–C, which includes an attestation to breach
of contract liability between parties, with potential to collect damages for failure to
perform.)

Supporting Documentation:
Document 1
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 2
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 3
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 4
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
QE Explanation:

Question 2: If your organization changed data analytics/warehousing vendors or experienced
contracting changes related to individuals/organizations/vendors handling QE Medicare data or
QE Medicare data security, did your organization submit updated Phase 2 evidence, including a
new QECP Data Security Workbook?

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Note: Public and non-public performance reports that include QE Medicare data must not be
disseminated using a new data analytics/warehousing vendor prior to the new vendor (and lead
QE) submitting updated QECP Phase 2 evidence and obtaining CMS approval (see Section 4.2).





Yes, we submitted updated Phase 2 evidence, including a new QECP Data Security
Workbook, and received CMS approval. (Provide explanation below, including
vendor name(s) for which evidence was submitted.)
No, we are currently in the process of submitting updated Phase 2 evidence,
including a new QECP Data Security Workbook. (Provide explanation below,
including vendor name(s) for which evidence will be submitted.)
No, we have not begun to submit updated Phase 2 evidence, including a new QECP
Data Security Workbook. (Provide explanation below, including vendor name(s) for
which evidence will be submitted.)
Not applicable, we do not anticipate contractor changes, or our contractor changes
do not involve data analytics/warehousing vendors.

Supporting Documentation:
Document 1
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 2
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 3
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 4
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
QE Explanation:

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Element 1.4: Identify changes to the QE’s ability to obtain claims data from at least one
other source to combine with the QE Medicare data
Question 3: Is your organization planning to report on the same geographic areas and level of
analysis identified in the pre-filled text box below?
List of current geographic areas and levels of analysis:
(The QE’s QECP Program Manager pre-fills this list)





Yes
No, the geographic area has changed. (Submit a new QECP Data Source
Attestation.)
No, the level of analysis has changed. (Enter the new level of analysis in the
explanation box.)
No, the geographic area AND level of analysis have changed. (Submit a new QECP
Data Source Attestation AND enter the new level of analysis in the explanation
box.)

Supporting Documentation:
Document 1
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 2
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 3
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 4
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________

QE Explanation:

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Question 4: Does your organization still receive the same sources and amounts of other-payer
claims data for the approved geographic areas in the pre-filled text box below?
List of current data suppliers and amount of data provided:
(The QE’s QECP Program Manager pre-fills this list)
Note: A QE may not, under any circumstances, use a measure, create a report, or issue a report
after the amount of claims data from other sources available to the QE decreases until the
QECP team determines either (1) that the remaining claims data are sufficient or (2) that the QE
has collected adequate additional data to address any identified deficiencies.



Yes
No, the amount of other-payer claims data received by our organization has
increased. (Submit a new QECP Data Source Attestation.)
 No, the amount of other-payer claims data received by our organization has
decreased. (Submit a new QECP Data Source Attestation. Provide an
explanation below, by data supplier name, of the reason that the data source
is no longer available to your organization, or the reason that the amount of
data received by the supplier has decreased. Submit documentation
demonstrating that the remaining claims data from other sources are
sufficient to address methodological concerns regarding sample size and
reliability.)

Supporting Documentation:
Document 1
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 2
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 3
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 4
Document Name: _________________________________________________
Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________

QE Explanation:

Element 2.1: Identify changes to the QE’s data security and privacy policies and procedures
Question 5: Does the annotated physical network diagram submitted by your organization still
accurately demonstrate (1) how sites that access the QE Medicare data are connected, and (2)
how QE Medicare data flow through your organization from receipt to public reporting (including
the confidential provider corrections and appeals process)? This includes Internet, wide area
network, local area network, and virtual private network connections.
Current Annotated Physical Network/QE Data Flow Diagram:
(The QE’s QECP Program Manager uploads this diagram)


Yes
 No (Submit an updated annotated physical network/QE data flow diagram. Refer to
Questions 1 and 2 for requirements related to changes in contractual relationships
with data analytics/warehousing vendors.)
Supporting Documentation:
Document 1
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 2
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 3
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
QE Explanation:
Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Question 6: Since Phase 2 approval, or submission of your organization’s most recent QECP
Annual Report, has your organization experienced any significant changes to data security and
privacy policies and procedures?
A significant change is defined in NIST Special Publication (SP) 800-37 as a change that is likely
to affect the security state of an information system or its environment of operation. The
examples listed below are significant only when they meet the threshold established in the NIST
definition above.
Significant changes to an information system include:
 Installation of a new or upgraded operating system, middleware component, or
application;
 Modifications to system ports, protocols, or services;
 Installation of a new or upgraded hardware platform;
 Modifications to cryptographic modules or services; or
 Modifications to security controls.
Examples of significant changes to the environment of operation may include, but are not
limited to:
 Moving to a new facility;
 Change in vendors, business partners, or service providers;
 Changes in data hosting providers;
 Changes in Internet service providers used to transmit QE Medicare data;
 Changes in staff with primary responsibility for data security;
 Adding new core missions or business functions;
 Data breaches and other violations of the CMS DUA;
 Adding or removing individuals from the CMS DUA;
 Acquiring specific and credible threat information that the organization is being
targeted by a threat source; or
 Establishing new/modified laws, directives, policies, or regulations.
If there is any uncertainty about whether a change in a data security program is significant and
should therefore be reported, please consult with the QECP team
([email protected]) to determine the appropriate next steps.


Yes (Describe below the changes, including dates when each change
occurred.)
 No
QE Explanation:

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Element 2.3 & 2.4: Identify changes to the corrections process; identify any changes related
to the secure transmission of beneficiary data
Question 7: Referring to the confidential provider corrections and appeals process your
organization submitted during its Phase 3 application, does your organization anticipate any
changes to this process prior to its next reporting cycle? This includes any changes to your
organization’s privacy and security protections for the release of beneficiary identifiers and/or
claims data to providers.
 Yes (Provide an explanation of the changes below. These changes must be
reflected in the physical network/QE data flow diagram provided under
Question 5. Changes related to contractual relationships with data
analytics/warehousing vendors are subject to the requirements of Questions 1
and 2.)
 No
QE Explanation:

Element 3.1: Identify changes to standard measures the QE intends to report in its next
public reporting cycle
Question 8: Does your organization intend to continue reporting the following standard measures
in its next public reporting cycle?
List of current standard measures:
(The QE’s QECP Program Manager pre-fills this list)
Note: QEs are required to notify the QECP team of any new standard measures it wishes to add
to its approved list of measures at least 30 days before its intended confidential performance
release to providers for the correction and appeal process.
 Yes
 No (Provide an explanation of the standard measures that will be added or
removed in your organization’s next public reporting cycle. For measures that

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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will be added, submit a revised QECP Measure Information Workbook,
accompanied by the required supporting documentation for Element 3.1).

Supporting Documentation:
Document 1
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 2
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 3
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________

QE Explanation:

Elements 3.2: Identify changes to alternative measures the QE intends to report in its next
public reporting cycle
Question 9: Does your organization intend to continue reporting the following alternative
measures in its next public reporting cycle?
List of current alternative measures:
(The QE’s QECP Program Manager pre-fills this list)
Note: QEs are required to notify the QECP team of any alternative measures they wish to add to
their approved list of measures. QEs are strongly encouraged to notify the QECP team of any new
alternative measures at least 90 days before the intended confidential performance report
release to providers.
 Yes
 No (Provide an explanation of the alternative measures that will be added or
removed in your organization’s next public reporting cycle. For measures that

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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will be added, submit a revised QECP Measure Information Workbook,
accompanied by the required supporting documentation for Element 3.2).

Supporting Documentation:
Document 1
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 2
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 3
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________

QE Explanation:

Element 3.3: Identify changes in the design of reports for providers and the public
Question 10: Does your organization anticipate changes in the appearance or content of its
provider or public report during its next reporting cycle? A “change” is defined as a significant
modification in provider ratings approach, the level of analysis for reported measures,
comparative reporting by product line, or website address, for example, but excludes changes
due to the addition or removal of performance measures.
Note: QEs must notify the QECP team of changes to the provider and/or public prototype report
and submit to the QECP team the new prototype report(s) at least 30 days before the intended
confidential release to providers.


Yes (Provide an explanation of the changes below, and submit the revised
provider and/or public report prototype.)
 No
Supporting Documentation:

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Document 1
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 2
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 3
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
QE Explanation:

Question 11: Referring to the dissemination plan your organization submitted during its Phase 3
application, does your organization anticipate any changes to its dissemination plan for informing
intended audiences of the issuance of its QE performance reports? This includes anticipated
changes to the public report release schedule and frequency.
Current Provider and Public Report Dissemination Plan:
(The QE's QECP Program Manager uploads this diagram)
Note: QEs must notify the QECP team of changes in the dissemination plan for sharing reports
with the public and submit the new plans at least 30 days before the intended confidential
performance report release to providers.



Yes (Provide an explanation of the changes below.)
No

QE Explanation:

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Section 5: Attestation
Instructions: Prior to a reapplication being submitted as final, the contents of the reapplication must be
accompanied with a completed attestation from an individual at the entity authorized to attest to its
accuracy and completion.
To the best of my knowledge and belief, all data in this reapplication are true and correct, the document
has been duly authorized by the governing body of the reapplicant, and the reapplicant will comply with
the terms and conditions of the award and applicable Federal requirements awarded.

Authorized Representative’s Name (printed) _________________________________________
Authorized Representative’s Title (printed) __________________________________________

Signature_____________________________________________ Date ____________________

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Section 6: Additional Supporting Documentation
Instructions: Please describe all additional supporting documentation submitted in conjunction with this
reapplication that is not listed in Section 4.
1.

Standard: _____________
Element: _____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

2.

Standard: _____________
Element: _____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

3.

Standard: _____________
Element: _____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

4.

Standard: _____________
Element: _____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

5.

Standard: _____________
Element: _____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

6.

Standard: _____________
Element: _____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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