Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey for the Merit-Based Incentive Payment System (MIPS) (CMS-10450)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10450 CAHPS Registration Guide	Form and Instruction	Modified	Available
Form CMS-10450 CAHPS for MIPS Group Registration	Form and Instruction	Modified	Repair queued
Form CMS-10450 Appendix F: Vendor Form	Form and Instruction	Modified	Available
Form CMS-10450 CAHPS for MIPS Survey Vendor Application	Form and Instruction	Modified	Repair queued
Form CMS-10450 CAHPS for MIPS CATI Script	Form and Instruction	Modified	Available
Form CMS-10450 Mail Survey	Form	Modified	Available
Form CMS-10450 CAHPS for MIPS Survey Beneficiary Participation	Form	Modified	Repair queued
CMS-10450-Supporting-Statement-B-FINAL.docx	Supporting Statement B	Uploaded 2024-02-13	Repair queued
CMS-10450-Supporting-Statement-A-2-13-24.docx	Supporting Statement A	Uploaded 2024-02-13	Repair queued
Appendix G Technical References.docx	Supplementary Document	Uploaded 2018-12-13	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
227777	CAHPS for MIPS Group Registration	Form and Instruction	Modified	CAHPS Registration Guide
227777	CAHPS for MIPS Group Registration	Form and Instruction	Modified
227776	CAHPS for MIPS Survey Vendor Application	Form and Instruction	Modified	Appendix F: Vendor Form
227776	CAHPS for MIPS Survey Vendor Application	Form and Instruction	Modified
206234	CAHPS for MIPS Survey Beneficiary Participation	Form and Instruction	Modified	CAHPS for MIPS CATI Script
206234	CAHPS for MIPS Survey Beneficiary Participation	Form	Modified	Mail Survey
206234	CAHPS for MIPS Survey Beneficiary Participation	Form	Modified
206234	CAHPS for MIPS Survey Beneficiary Participation	Instruction	Modified

ICR Details

OMB Control No: 0938-1222	ICR Reference No: 202401-0938-011
Status: Historical Active	Previous ICR Reference No: 202107-0938-012
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey for the Merit-Based Incentive Payment System (MIPS) (CMS-10450)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/09/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/15/2024
Terms of Clearance: Approved consistent with the understanding that in the next revision/extension of the package, the agency will update the race/ethnicity question in this information collection to be in compliance with the updated SPD 15 (effective as of March 28, 2024).

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2026	36 Months From Approved	07/31/2024
Responses	25,776	0	30,249
Time Burden (Hours)	5,867	0	6,902
Cost Burden (Dollars)	0	0	0

---

Abstract: Section 1848(q) of the Social Security Act, as amended by section 101 of the Medicare Access and CHIP Reauthorization Act of 2015, authorizes the establishment of a Merit-based Incentive Payment System (MIPS) for eligible clinicians. Beginning in CY 2017, eligible clinicians are required to collect and submit data on four performance categories to CMS (quality, cost, advancing care information and improvement activities). This program replaces and consolidates portions of the PQRS, Value-based Modifier, and the Medicare EHR Incentive Program. The Act also establishes a second track, Advanced Alternative Payment Models (APMs) for clinicians to participate in instead of MIPS. The CAHPS survey information is used for quality reporting to collect data on fee-for-service Medicare beneficiaries’ experiences of care with eligible clinicians participating in MIPS, the Physician Compare website, and annual statistical reports describing MIPS data for all MIPS eligible clinicians.

---

Authorizing Statute(s): US Code: 42 USC 1395w-4 Name of Law: MACRA of 2015
   PL: Pub.L. 111 - 148 10331 Name of Law: Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 10331 Name of Law: Affordable Care Act
US Code: 42 USC 1395w-4 Name of Law: MACRA of 2015

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 71573	10/17/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 2622	01/16/2024
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
CAHPS for MIPS Group Registration	CMS-10450	CAHPS Registration Guide
CAHPS for MIPS Survey Beneficiary Participation	CMS-10450, CMS-10450	Mail Survey ,   CAHPS for MIPS CATI Script
CAHPS for MIPS Survey Vendor Application	CMS-10450	Appendix F: Vendor Form

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	25,776	30,249	0	-4,473	0	0
Annual Time Burden (Hours)	5,867	6,902	0	-1,035	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: There has been a decrease in the number of responses from 30,249 to 25,776. The burden hours decreased by 1,035 from 6,902 to 5,867.

---

Annual Cost to Federal Government: $1,478,500

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Yes

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/15/2024

---