Application and Re-application processes

Application and Triennial Re-application to Be a Qualified Entity to Receive Medicare Data for Performance Measurement (ACA Section 10332) (CMS-10394)

OMB: 0938-1144

IC ID: 198017

Documents and Forms
Document Name
Document Type
Form and Instruction
Instruction
Instruction
Instruction
Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Application and Re-application processes
 
No Modified
 
Voluntary
 
42 CFR 401.703a

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10394 Application 6_PaperQECPReapplication.pdf Yes Yes Fillable Fileable Signable
Form and Instruction CMS-10394 QECP Measure Production QA Worksheet 4_QE CP Phase 3 App List_Final.pdf Yes Yes Fillable Fileable Signable
Form and Instruction CMS-10394 QECP Measure Information Workbook 5_QECP Phase 3 MIW List_Final.pdf Yes Yes Fillable Printable
Instruction 6_Reapplicaiton Requiremetns List .pdf Yes Yes Printable Only
Form and Instruction CMS-10394 QECP Phase 1 Data Source Attestation Requirements 2_QECP Phase 1 DSA Requirements_Final.pdf Yes Yes Fillable Printable
Form and Instruction CMS-10394 Qualified Entity Certification Program Data Security Review (QECP DSR) 3_QECP Data Security Review 2020 FINAL v1.1_508.pdf Yes Yes Fillable Printable
Form and Instruction CMS-10394 Letter of Commitment Template 5 QECP Letter of Commitment Template.pdf Yes Yes Fillable Printable
Instruction QECPProgramGuide.pdf Yes Yes Printable Only

Health Health Care Services

 

30 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 30 0 20 0 10 0
Annual IC Time Burden (Hours) 3,800 0 -1,200 0 5,000 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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