Appendix H1 Improvement Activities Performance Category, 2023 Call f

Improvement Activities Performance Category

CY 2023 Call for Improvement Activities Submission Form

Improvement activities recommended for inclusion or modification should be sent using the Improvement Activities Submission Template (below) to the email: [email protected]. Stakeholders will receive an email confirmation for their submission. Improvement activities submitted between February 1 and July 1, 2023 will be considered for inclusion for the CY 2025 performance period/2027 MIPS payment year. Improvement activities submitted after July 1, 2023 will be considered for inclusion in future years of the Quality Payment Program. During a public health emergency (PHE), nominations will be accepted outside of the February 1 through July 1 submission period as long as the improvement activity is relevant to the PHE. All fields of this form must be completed in order for your submission to be considered. Stakeholders should submit a modification submission if the improvement activity they submitted or one that refers to a program or policy they manage requires an update.

We also refer submitters to the 2023 MIPS Improvement Activities list on the CMS Quality Payment Program resource library, which lists the complete Inventory of current improvement activities for the CY 2023 performance period/2025 MIPS payment year. Submitters should ensure that proposed new activities do not duplicate existing ones.

MIPS improvement activities considered for selection must meet all 8 of the required acceptance criteria below:

• Relevance to an existing improvement activities subcategory (or a proposed new subcategory);

• Importance of an activity toward achieving improved beneficiary health outcomes;

• Feasible to implement, recognizing importance in minimizing burden, including, to the extent possible, for small practices, practices in rural areas, or practices in areas designated as geographic Health Professional Shortage Areas (HPSAs) by the Health Resources and Services Administration (HRSA);

• Evidence supports that an activity has a high probability of contributing to improved beneficiary health outcomes;

• Can be linked to existing and related MIPS quality, Promoting Interoperability, and cost measures as applicable and feasible;

• CMS is able to validate the activity;

• Does not duplicate other improvement activities in the Inventory;* and

• Should drive improvements that go beyond purely common clinical practices.*

*Submission criterion that was new for the CY 2022 Call for Improvement Activities

MIPS improvement activities considered for selection can also meet one or more of the optional acceptance criteria below. Meeting one or more of the optional criteria may increase a submission’s chances of being added to the Inventory:

• Alignment with patient-centered medical homes;

• Support for the patient’s family or personal caregiver;

• Responds to a PHE as determined by the Secretary;

• Addresses improvements in practice to reduce health care disparities;

• Focus on meaningful actions from the person and family’s point of view; and

• Representative of activities that multiple individual MIPS eligible clinicians or groups could perform (for example, primary care, specialty care).

Proposed New Improvement Activities Recommended for Inclusion in the Quality Payment Program: Submission Template

Activity Sponsor: Provide entity name, URL, and individual contact information: name, address, phone, email—in case we need to contact submitter.
CMS NPI # or Sponsor Type: Include NPI number, or indicate other entity type, e.g., EHR vendor, specialty group, or other—25 words or less.
Activity Title: Provide the activity title only—10 words or less.
Activity Description: Provide a brief description of the proposed activity—300 words or less. Please be as specific as possible about what the activity entails. E.g., “MIPS eligible clinician must perform/ do XXXX.”
Proposed Subcategory: Select the ONE (1) subcategory under which your proposed improvement activity best fits from among the following eight options: Achieving Health Equity Behavioral and Mental Health Beneficiary Engagement Care Coordination Emergency Response and Preparedness Expanded Practice Access Patient Safety and Practice Assessment Population Management
Rationale and Supporting Documentation (e.g., peer-reviewed articles, other publications, websites) Describe how this activity would meet the acceptance criteria listed above. Provide supporting documentation that indicates that this activity has been used successfully in the field, and that it can lead to practice quality improvement and improvement in patient health, experience, etc. Please provide citations of or links to established processes, validated tools, etc., that are referenced in the activity.
Documentation to Use as Proof of Activity Completion: Include data or primary sources that a MIPS eligible clinician could use to validate performance of the improvement activity (e.g., medical charts, office schedules, data reports, quality improvement reports or submissions to funders/payers, meeting minutes).
Level of Effort: Include data, primary sources or personal experience to substantiate the level of effort the submitter anticipates are required to complete the proposed improvement activity on an annual basis. (This estimate could be in hours/days, dollars, staffing needs/FTE, external resources/supports or any combination thereof).

Proposed Modifications to Improvement Activities Recommended for Inclusion in the Quality Payment Program: Submission Template

Existing IA Proposed to Modify (please list IA subcategory/number, e.g., IA_AHE_1):
Modification proposed: Please check off the type of modification you are proposing	Weight Subcategory Description
Please list the modification you propose INCLUDING a rationale for why you believe this modification is warranted.

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 4.4 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] 

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