Information Collection

CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary

IC 250664 under ICR 202208-0938-004 · OMB 0938-1314.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1314 can be found here:

Documents and Forms

Document Name Document Type
Form Appendix A CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary Form and Instruction
Appendix A 2023 QCDR and Registry Self-nomination User Guide Appendix A 2023 QCDR and Registry Self-Nomination User Guide_508.pdf Form and Instruction
Appendix A 2023 QCDR and Registry Self-nomination User Guide Appendix A 2023 QCDR and Registry Self-Nomination User Guide_508.pdf Form and Instruction
Appendix B Payer Initiated Submission Form Appendix B 2022 Payer Initiated Submission Form.pdf Form
Appendix B Payer Initiated Submission Form Appendix B 2022 Payer Initiated Submission Form.pdf Form
Appendix C Eligible Clinician Initiated Submission Form Appendix C 2022 Clinician Initiated Submission Form.pdf Form
Appendix C Eligible Clinician Initiated Submission Form Appendix C 2022 Clinician Initiated Submission Form.pdf Form
Appendix D Submission Form for Requests for Qualifying Alternative Appendix D 2022 All-Payer QP Data Submission Form.pdf Form
Appendix D Submission Form for Requests for Qualifying Alternative Appendix D 2022 All-Payer QP Data Submission Form.pdf Form
Appendix E Data Template for Candidate Measures Appendix E 2021 MUC Data Template.pdf Form
Appendix E Data Template for Candidate Measures Appendix E 2021 MUC Data Template.pdf Form
Appendix F 2022 Peer Reviewed Journal Article Requirement Template Appendix F 2022 MIPS Peer Reviewed Template .pdf Form
Appendix F 2022 Peer Reviewed Journal Article Requirement Template Appendix F 2022 MIPS Peer Reviewed Template .pdf Form
Appendix G Promoting Interoperability Performance Category, 2022 Ca Appendix G 2022 PI Call for Measures Submission Form.pdf Form
Appendix G Promoting Interoperability Performance Category, 2022 Ca Appendix G 2022 PI Call for Measures Submission Form.pdf Form
Appendix H Improvement Activities Performance Category, 2022 Call f Appendix H 2022 IA Call for Activities Submission Form.pdf Form
Appendix H Improvement Activities Performance Category, 2022 Call f Appendix H 2022 IA Call for Activities Submission Form.pdf Form
Appendix I 2021 Hardship Exception Application Form Appendix I 2021 Promoting Operability Hardship Exception Application.pdf Form
Appendix I 2021 Hardship Exception Application Form Appendix I 2021 Promoting Operability Hardship Exception Application.pdf Form
Appendix J 2021 Extreme and Uncontrollable Circumstances Applicatio Appendix J 2020 Extreme and Uncontrollable Circumstances Reweighting Application.pdf Form
Appendix J 2021 Extreme and Uncontrollable Circumstances Applicatio Appendix J 2020 Extreme and Uncontrollable Circumstances Reweighting Application.pdf Form
Appendix K 2022 MVP Candidates: Instructions and Template Appendix K 2022 MVP Development Standardized Template.pdf Form and Instruction
Appendix K 2022 MVP Candidates: Instructions and Template Appendix K 2022 MVP Development Standardized Template.pdf Form and Instruction
Appendix L 2020 Partial QP Election Form Appendix L Partial QP Submission Form.pdf Form
Appendix L 2020 Partial QP Election Form Appendix L Partial QP Submission Form.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.1375 42 CFR 414.1445 42 CFR 414.1395 42 CFR 414.1335 42 CFR 414.1380 42 CFR 414.1360 42 CFR 414.1400 42 CFR 414.1430 42 CFR 414.1325 42 CFR 414.1440

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Appendix A	2023 QCDR and Registry Self-nomination User Guide	Appendix A 2023 QCDR and Registry Self-Nomination User Guide_508.pdf	Yes	Yes	Fillable Fileable
Form	Appendix B	Payer Initiated Submission Form	Appendix B 2022 Payer Initiated Submission Form.pdf	Yes	Yes	Fillable Fileable
Form	Appendix C	Eligible Clinician Initiated Submission Form	Appendix C 2022 Clinician Initiated Submission Form.pdf	Yes	Yes	Fillable Fileable
Form	Appendix D	Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option	Appendix D 2022 All-Payer QP Data Submission Form.pdf	Yes	Yes	Fillable Fileable
Form	Appendix E	Data Template for Candidate Measures	Appendix E 2021 MUC Data Template.pdf	Yes	Yes	Fillable Fileable
Form	Appendix F	2022 Peer Reviewed Journal Article Requirement Template	Appendix F 2022 MIPS Peer Reviewed Template .pdf	Yes	Yes	Fillable Fileable
Form	Appendix G	Promoting Interoperability Performance Category, 2022 Call for Measures Submission Form	Appendix G 2022 PI Call for Measures Submission Form.pdf	Yes	Yes	Fillable Fileable
Form	Appendix H	Improvement Activities Performance Category, 2022 Call for Activities Submission Form	Appendix H 2022 IA Call for Activities Submission Form.pdf	Yes	Yes	Fillable Fileable
Form	Appendix I	2021 Hardship Exception Application Form	Appendix I 2021 Promoting Operability Hardship Exception Application.pdf	Yes	Yes	Fillable Fileable
Form	Appendix J	2021 Extreme and Uncontrollable Circumstances Application Form	Appendix J 2020 Extreme and Uncontrollable Circumstances Reweighting Application.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	Appendix K	2022 MVP Candidates: Instructions and Template	Appendix K 2022 MVP Development Standardized Template.pdf	Yes	Yes	Fillable Fileable
Form	Appendix L	2020 Partial QP Election Form	Appendix L Partial QP Submission Form.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 180,365	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to New Statute	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	344,023	2,034	19,019	322,970
Annual IC Time Burden (Hours)	1,469,234	-11,039	90,254	1,390,019
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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