Appendix L1 2022 Partial QP Election Form (for submission in CY 2023

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2022 Qualifying APM Participant (QP) Performance Period

Partial QP Election Form

Dear [APM_Entity_Name]:

Based on CMS’ QP threshold calculations for performance year 2022 (payment adjustment year 2024), there are eligible clinicians in «APM_Entity_Name» that are Partial QPs. Accordingly, [APM_Entity_Name] is to elect whether to report to MIPS. If [APM_Entity_Name] elects to report to MIPS, all MIPS eligible clinicians in [APM_Entity_Name] that are Partial QPs will be subject to the MIPS reporting requirements and payment adjustments for that year. To elect to report or not report to MIPS, [APM_Entity_Name] is to complete and submit this election form accordingly to [email protected] no later than March 31, 2023.

In the absence of making an explicit election, the MIPS eligible clinicians in [APM_Entity_Name] will not participate in MIPS. Therefore, the Partial QPs in [APM_Entity_Name] will participate in MIPS and receive a corresponding MIPS payment adjustment only if the APM Entity elects for the eligible clinicians to participate in MIPS.

If [APM_Entity_Name] elects not to report to MIPS, the clinicians can still report to MIPS though they will not be subject to the MIPS payment adjustment. This election is only applicable to performance year 2022 (payment adjustment year 2024). If you have questions, please contact [email protected].

Election Form

Please indicate whether [APM_Entity_Name] elects to report to MIPS by putting an “X” by one of the options listed below:

☐ [APM_Entity_Name] elects to report to MIPS.

☐ [APM_Entity_Name] elects not to report to MIPS.

Signature

I certify that I am legally authorized to bind [APME] to this election.

Signature: ____________________________ Print Name: __________________________

Title: _________________________________ Date: __________________________

Please email the selected and signed form to [email protected] by March 31, 2023.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1314 (Expiration date: 01/31/2025). The time required to complete this information collection is estimated to average 0.25 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact QPP at [email protected]