Information Collection

CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary

IC 250664 under ICR 202301-0938-017 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form Appendix A CY 2023 Performance Period/2025 MIPS Payment Year Burden Summary	Form and Instruction
Appendix A Self-Nomination User Guide for Qualified Clinical Data R Appendix A 2023MIPS QCDR and Registry Self-Nomination User Guide.docx	Form and Instruction
Appendix A Self-Nomination User Guide for Qualified Clinical Data R Appendix A 2023MIPS QCDR and Registry Self-Nomination User Guide.docx	Form and Instruction
Appendix B1 2023 Submission Form for Other Payer Requests for Other Appendix B1 2023 Payer Initiated Submission Form.pdf	Form
Appendix B1 2023 Submission Form for Other Payer Requests for Other Appendix B1 2023 Payer Initiated Submission Form.pdf	Form
Appendix C1 2023 Submission Form for Eligible Clinician and APM Enti Appendix C1 2023 Eligible Clinician Initiated Submission Form.docx	Form and Instruction
Appendix C1 2023 Submission Form for Eligible Clinician and APM Enti Appendix C1 2023 Eligible Clinician Initiated Submission Form.docx	Form and Instruction
Appendix D1 2023 Submission Form for Requests for Qualifying Alterna Appendix D1 2023 All-Payer QP Data Submission Form.docx	Form and Instruction
Appendix D1 2023 Submission Form for Requests for Qualifying Alterna Appendix D1 2023 All-Payer QP Data Submission Form.docx	Form and Instruction
Appendix E1 Measures under Consideration 2022 (for the 2024 performa Appendix E1 2022 MUC Data Template.docx	Form and Instruction
Appendix E1 Measures under Consideration 2022 (for the 2024 performa Appendix E1 2022 MUC Data Template.docx	Form and Instruction
Appendix F1 2023 Peer Reviewed Journal Article Requirement Template Appendix F1 2022 MIPS Peer-Reviewed Journal Article Requirement Template.docx	Form and Instruction
Appendix F1 2023 Peer Reviewed Journal Article Requirement Template Appendix F1 2022 MIPS Peer-Reviewed Journal Article Requirement Template.docx	Form and Instruction
Appendix G1 Promoting Interoperability Performance Category, 2023 Ca Appendix G1 2023 PI Call for Measures Submission Form.pdf	Form and Instruction
Appendix G1 Promoting Interoperability Performance Category, 2023 Ca Appendix G1 2023 PI Call for Measures Submission Form.pdf	Form and Instruction
Appendix H1 Improvement Activities Performance Category, 2023 Call f Appendix H1 2023 IA Call for Activities Submission Form.docx	Form and Instruction
Appendix H1 Improvement Activities Performance Category, 2023 Call f Appendix H1 2023 IA Call for Activities Submission Form.docx	Form and Instruction
Appendix I 2022 MIPS Promoting Interoperability Hardship Exception Appendix I 2022 MIPS Promoting Interoperability Hardship Exception Application Guide.pptx	Form and Instruction
Appendix I 2022 MIPS Promoting Interoperability Hardship Exception Appendix I 2022 MIPS Promoting Interoperability Hardship Exception Application Guide.pptx	Form and Instruction
Appendix J 2022 MIPS Extreme and Uncontrollable Circumstances Excep Appendix J 2022 Extreme and Uncontrollable Circumstances Exception Application Guide.pptx	Form and Instruction
Appendix J 2022 MIPS Extreme and Uncontrollable Circumstances Excep Appendix J 2022 Extreme and Uncontrollable Circumstances Exception Application Guide.pptx	Form and Instruction
Appendix K1 2023 MVP Candidates: Instructions and Template Appendix K1 2023 MVP Development Standardized Template v2.docx	Form and Instruction
Appendix K1 2023 MVP Candidates: Instructions and Template Appendix K1 2023 MVP Development Standardized Template v2.docx	Form and Instruction
Appendix L1 2022 Partial QP Election Form (for submission in CY 2023 Appendix L1 Partial QP Submission Form.docx	Form and Instruction
Appendix L1 2022 Partial QP Election Form (for submission in CY 2023 Appendix L1 Partial QP Submission Form.docx	Form and Instruction
Appendix B2 2023 Payer Initiated Submission Form Crosswalk.docx Crosswalk: Appendix B1	IC Document
Appendix B2 2023 Payer Initiated Submission Form Crosswalk.docx Crosswalk: Appendix B1	IC Document
Appendix C2 2023 Eligible Clinician Initiated Submission Form Crosswalk.docx Crosswalk: Appendix C1	IC Document
Appendix C2 2023 Eligible Clinician Initiated Submission Form Crosswalk.docx Crosswalk: Appendix C1	IC Document
Appendix D2 2023 All-Payer QP Data Submission Form Crosswalk.docx Crosswalk: Appendix D1	IC Document
Appendix D2 2023 All-Payer QP Data Submission Form Crosswalk.docx Crosswalk: Appendix D1	IC Document
Appendix E2 2022 MUC Data Template Crosswalk.docx Crosswalk: Appendix E1	IC Document
Appendix E2 2022 MUC Data Template Crosswalk.docx Crosswalk: Appendix E1	IC Document
Appendix F2 2022 MIPS Peer-Reviewed Journal Article Requirement Template Crosswalk.docx Crosswalk: Appendix F1	IC Document
Appendix F2 2022 MIPS Peer-Reviewed Journal Article Requirement Template Crosswalk.docx Crosswalk: Appendix F1	IC Document
Appendix G2 2023 PI Call for Measures Submission Form Crosswalk.docx Crosswalk: Appendix G1	IC Document
Appendix G2 2023 PI Call for Measures Submission Form Crosswalk.docx Crosswalk: Appendix G1	IC Document
Appendix H2 2023 IA Call for Activities Crosswalk.docx Crosswalk: Appendix H1	IC Document
Appendix H2 2023 IA Call for Activities Crosswalk.docx Crosswalk: Appendix H1	IC Document
Appendix K2 2023 MVP Submission Template Crosswalk.pdf Crosswalk: Appendix K1	IC Document
Appendix K2 2023 MVP Submission Template Crosswalk.pdf Crosswalk: Appendix K1	IC Document
Appendix L2 2022 Partial QP Submission Form Crosswalk.docx Crosswalk: Appendix L1	IC Document
Appendix L2 2022 Partial QP Submission Form Crosswalk.docx Crosswalk: Appendix L1	IC Document

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

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Appendix A	Self-Nomination User Guide for Qualified Clinical Data Registries (QCDRs) and Qualified Registries	Appendix A 2023MIPS QCDR and Registry Self-Nomination User Guide.docx	Yes	Yes	Fillable Fileable
Form	Appendix B1	2023 Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form)	Appendix B1 2023 Payer Initiated Submission Form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	Appendix C1	2023 Submission Form for Eligible Clinician and APM Entity Requests for Other Payer Advanced Alternative Payment Model Determinations (Eligible Clinician Initiated Submission Form)	Appendix C1 2023 Eligible Clinician Initiated Submission Form.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Appendix D1	2023 Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option	Appendix D1 2023 All-Payer QP Data Submission Form.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Appendix E1	Measures under Consideration 2022 (for the 2024 performance period), Data Template for Candidate Measures	Appendix E1 2022 MUC Data Template.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Appendix F1	2023 Peer Reviewed Journal Article Requirement Template	Appendix F1 2022 MIPS Peer-Reviewed Journal Article Requirement Template.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Appendix G1	Promoting Interoperability Performance Category, 2023 Call for Measures Submission Form	Appendix G1 2023 PI Call for Measures Submission Form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	Appendix H1	Improvement Activities Performance Category, 2023 Call for Activities Submission Form	Appendix H1 2023 IA Call for Activities Submission Form.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Appendix I	2022 MIPS Promoting Interoperability Hardship Exception Application Guide (for submission in CY 2023)	Appendix I 2022 MIPS Promoting Interoperability Hardship Exception Application Guide.pptx	Yes	Yes	Fillable Fileable
Form and Instruction	Appendix J	2022 MIPS Extreme and Uncontrollable Circumstances Exception Application Guide (for submission in CY2023	Appendix J 2022 Extreme and Uncontrollable Circumstances Exception Application Guide.pptx	Yes	Yes	Fillable Fileable
Form and Instruction	Appendix K1	2023 MVP Candidates: Instructions and Template	Appendix K1 2023 MVP Development Standardized Template v2.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Appendix L1	2022 Partial QP Election Form (for submission in CY 2023)	Appendix L1 Partial QP Submission Form.docx	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: 159,528

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 %

table that charts list of burden
	Approved	Program Change Due to New Statute	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	159,528	1,285	-164,727	322,970
Annual IC Time Burden (Hours)	713,860	-3,708	-672,451	1,390,019
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk: Appendix B1	Appendix B2 2023 Payer Initiated Submission Form Crosswalk.docx	01/25/2023
Crosswalk: Appendix C1	Appendix C2 2023 Eligible Clinician Initiated Submission Form Crosswalk.docx	01/25/2023
Crosswalk: Appendix D1	Appendix D2 2023 All-Payer QP Data Submission Form Crosswalk.docx	01/25/2023
Crosswalk: Appendix E1	Appendix E2 2022 MUC Data Template Crosswalk.docx	01/25/2023
Crosswalk: Appendix F1	Appendix F2 2022 MIPS Peer-Reviewed Journal Article Requirement Template Crosswalk.docx	01/25/2023
Crosswalk: Appendix G1	Appendix G2 2023 PI Call for Measures Submission Form Crosswalk.docx	01/25/2023
Crosswalk: Appendix H1	Appendix H2 2023 IA Call for Activities Crosswalk.docx	01/25/2023
Crosswalk: Appendix K1	Appendix K2 2023 MVP Submission Template Crosswalk.pdf	01/25/2023
Crosswalk: Appendix L1	Appendix L2 2022 Partial QP Submission Form Crosswalk.docx	01/25/2023

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