CMS-10450 CAHPS Registration Guide

2023 Registration Guide for the CAHPS for MIPS Survey

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Table of Contents
Section
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.

Introduction
Get Started
Access the CAHPS for MIPS Survey Registration System
Submit a New Registration for the CAHPS for MIPS Survey
Modify Information for an Existing Registration
View Your CAHPS for MIPS Survey Registration Summary
Delete Your 2023 Registration for the CAHPS for MIPS Survey
For More Information
Version History

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I. Introduction
This guide provides information and instructions on the Consumer Assessment of Healthcare Providers and Systems
(CAHPS) for Merit-based Incentive Payment System (MIPS) Survey registration process for the 2023 performance period.
Please review the 2023 CAHPS for MIPS Survey Overview Fact Sheet (PDF) for more information about administering the
CAHPS for MIPS Survey.

Registration Information
To register to administer the CAHPS for MIPS Survey, sign in to the Quality Payment Program website.
Registration opens on Monday, April 3, 2023, at 10 a.m. ET and closes on Friday, June 30, 2023, at 8 p.m. ET.

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To complete your organization’s registration, you need a Health Care Quality Information System (HCQIS) Access
Roles and Profile (HARP) account and the Security Official role for your organization. More information is provided in
Section III: Access the Registration System of this guide.

Definitions
•

Group: A single Taxpayer Identification Number (TIN) with 2 or more eligible clinicians (including at least one MIPS
eligible clinician), as identified by their individual National Provider Identifier (NPI), who have reassigned their
Medicare billing rights to the TIN.

•

Virtual group: A combination of 2 or more whole TINs (solo practitioners and/or groups with 10 or fewer clinicians,
including at least one MIPS eligible clinician) whose clinicians elected to participate in MIPS as part of a virtual group.
Only virtual groups that CMS approves and identifies as official virtual groups can participate in MIPS as a virtual
group for the 2023 performance year.

•

Subgroup: A subset of clinicians within a group (identified by a single TIN), which contains at least 2 clinicians, one
of whom is an individually eligible MIPS eligible clinician. Subgroup participation is only available for reporting a MIPS
Value Pathway (MVP).

•

Alternative Payment Model (APM) Entity: The group of eligible clinicians participating in an APM Entity, as
identified by a combination of the APM identifier, APM Entity identifier, TIN, and NPI for each participating eligible
clinician.

Note: The registration process outlined in this guide is applicable to groups, virtual groups, and APM Entities
registering for the CAHPS for MIPS Survey.
The registration process outlined in this guide doesn’t apply to subgroups that intend to administer the CAHPS for
MIPS Survey as 1 of their 4 required quality measures for MVP reporting. Learn more.

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Who doesn’t need to register for the CAHPS for MIPS Survey?
Medicare Shared Savings Program (Shared Savings Program) Accountable Care Organizations (ACOs).
•
•

Shared Savings Program ACOs are required to report the APM Performance Pathway (APP) so they are
automatically registered for the CAHPS for MIPS Survey which is a required measure under the APP.
Shared Savings Program ACOs don’t need to register but will still need to hire a CMS-approved vendor to administer
the CAHPS for MIPS Survey.

Who must register for the CAHPS for MIPS Survey?
APM Performance Pathway (APP): Groups and APM Entities (excluding Shared Savings Program ACOs) that choose to
report the APP must register because the CAHPS for MIPS Survey is a required measure when reporting through the
APP.

Who can register for the CAHPS for MIPS Survey?
Traditional MIPS: The CAHPS for MIPS Survey is an optional measure available to groups, virtual
groups, and APM Entities with 2 or more eligible clinicians reporting traditional MIPS.
•

The CAHPS for MIPS Survey can be reported as 1 of the 6 required quality measures in traditional
MIPS.

•

It also fulfills part of the requirement for the ‘Regularly Assess Patient Experience of Care and
Follow Up on Findings’ improvement activity (IA_BE_6).

•

Interested groups, virtual groups and APM Entities can follow the registration directions in this
resource; they must register by June 30, 2023, at 8 p.m. ET.

MIPS Value Pathways (MVPs): The CAHPS for MIPS Survey is an optional measure available to
groups, subgroups*, and APM Entities with 2 or more eligible clinicians that are registered to report certain
MVPs. (continued on next page)

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Before You Register:
The CAHPS for MIPS
Survey assesses the
experience of patients
receiving primary care
services and is,
therefore, most
appropriate for groups,
virtual groups,
subgroups*, and APM
Entities that provide
primary care services.

•

If the CAHPS for MIPS Survey is available within your selected MVP, it can be reported as 1 of the 4 required
quality measures.

•

Interested groups and APM Entities can follow the registration directions in this resource; they must register by
June 30, 2023, at 8 p.m. ET.

*Subgroups. Subgroups won’t follow the registration steps outlined in this resource. Subgroups interested in
administering the CAHPS for MIPS Survey as 1 of their 4 required quality measures for MVP reporting will complete their
registration through the QPP Service Center. If a subgroup registers for an MVP that includes the CAHPS for MIPS
Survey measure before June 30, 2023, a Service Center representative will follow up with the practice’s Security Official
who submitted the subgroup’s MVP registration to determine if the subgroup also intends to administer the CAHPS for
MIPS Survey. The Service Center representative will collect any additional information required to complete the
subgroup’s CAHPS for MIPS Survey registration by June 30, 2023, at 8 p.m. ET when the CAHPS for MIPS Survey
registration period closes.
For more information about MVP registration, please review the 2023 MVP Registration Form and Fact Sheet.

Is it possible we won’t be able to administer the CAHPS for MIPS Survey even if we register?
Yes. We conduct an assignment and sampling methodology process for organizations that are registered to administer
the CAHPS for MIPS Survey. Groups, subgroups, virtual groups, and APM Entities must meet minimum patient sampling
requirements to administer the 2023 CAHPS for MIPS Survey.
If an organization doesn’t meet the minimum patient sampling requirements for the CAHPS for MIPS Survey, we’ll notify
organizations indicating that they won’t be able to administer the CAHPS for MIPS Survey. We anticipate notifications will
be sent in the fall of 2023.
Groups, virtual groups, subgroups, and APM Entities (including Shared Savings Program ACOs reporting the
APP) that don’t meet minimum patient sampling requirements will qualify for a denominator reduction and the
CAHPS for MIPS Survey measure will be excluded from scoring.

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II. Get Started
Obtain Access
A representative of the organization will need an account that allows the representative to sign in to the
Quality Payment Program website and have the Security Official role for the organization to submit,
modify, or cancel a registration.
•

If you’re a returning user, sign in with your existing QPP account credentials.

•

If you’re a new user, you must first create a HARP account. Then you will sign in to the Quality
Payment Program website to request the Security Official role for your organization.

Review the documents specified below in the Quality Payment Program Access User Guide (ZIP) for
instructions to create an account and/or request the Security Official role for your organization.

Start the account
creation process
now to avoid any
delays in obtaining
an account and a
role with your
organization. The
registration period
closes on June 30,
2023, at 8 p.m. ET.

•

Register for a HARP Account provides information about creating a new HARP account.

•

Connect to an Organization provides information about requesting the Security Official role for your organization.

To determine if your organization already has an individual who can register the group, virtual group, or APM Entity to
administer the CAHPS for MIPS Survey, please contact QPP and provide the group's TIN, the virtual group identifier, or the
APM Entity identifier, and the name of the organization.

Prepare to Register for the CAHPS for MIPS Survey
Gather the following information before you begin to register your organization:
•

Determine Organization Size: 2-24 clinicians, 25-99 clinicians, or 100 or more clinicians.

•

Contact Information: First Name, Last Name, Phone Number, and Email.
o

Note: You must provide complete information for at least one contact to submit your registration.

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III. Access the CAHPS for MIPS Survey Registration System
You’ll be able to access the registration system between April 3, 2023 (10 a.m. ET) and June 30, 2023 (8 p.m. ET) by
signing in to the Quality Payment Program website.
Signing in will allow you to create new registrations, view or delete existing registrations, or modify information for existing
registrations for a group, virtual group, or APM Entity.
•

Reminder: Subgroups won’t follow this process to register for the CAHPS for MIPS Survey. Learn more about the
subgroup CAHPS registration process.

Note: This user guide may use the term “organization” when referring to information that applies to APM Entities, groups,
and virtual groups.
1. Go to the Quality Payment
Program website and click
Sign In in the upper righthand corner.
2. Enter your HARP User ID
and Password in the
requested fields and click
Sign In.
3. Click Yes, I agree for the
Statement of Truth.

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4. Complete the Two-Factor Authentication
If this is your first time signing in, you’ll be
prompted to set up two-factor authentication
which will be completed in your HARP account.
You’ll select a verification device (i.e., your cell
phone) where you wish to have your one-time
code sent each time you sign in.
If you’re a returning user, you’ll simply select the
registered verification device where you want the
one-time code to be sent.
Request a one-time code by selecting your
preferred device from the device dropdown, click
Send Code, enter the one-time code, and click
Verify.
Step 1. Select device from device drop
down and send code.

Step 2. Type in code and verify.

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5. Select Registration from the left-hand navigation panel.

Alternatively, you can select Start Registration from the home screen.

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6. From the Registration screen, select Register and Edit CAHPS Registration.

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7. If you have access to multiple organization types (“practices”, “virtual groups”, or “APM Entities”), you need to select
the organization type before you can complete the CAHPS registration for a specific organization.

In this example, the user’s account is
associated with APM Entities, virtual
groups, and practices.
After selecting the Practices tab, the
user would click Register Group for
CAHPS next to the appropriate
practice to start the CAHPS
registration.
You’ll only see tabs for the
organization types (APM Entities,
Virtual Groups, Practices) associated
with your account. Most users will
only see one organization type.

If you don’t have the ability to select Register and Edit CAHPS Registration, then you don’t have the required
Security Official role for the connected organization(s). This role is necessary to submit, modify, or delete a registration.
Review the Connect to an Organization section in the Quality Payment Program Access User Guide for
information about obtaining the correct Security Official role.

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8. At the top of the Register for CAHPS page, you will find your unique Registration ID and number of contacts
receiving updates for this registration. You may delete the CAHPS registration at any time during the registration
process by clicking the button on the upper right-hand side.
IMPORTANT: Changes made within the registration form will automatically be saved as the registration is completed
in real time.

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IV. Submit a New Registration for the CAHPS for MIPS Survey
Please follow the steps below when registering an organization for the first time or re-registering an organization that
deleted a previous registration.
If you don’t see the connected organization you are attempting to register for, you don’t have the required
Security Official role for that organization. This role is necessary to submit or delete a registration.
Review Connect to an Organization in the Quality Payment Program Access User Guide for information
about obtaining this role.

1. Organization Size
Select the Organization Size for the organization you want to register.

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2. Register for CAHPS: Add a Contact
Identify a contact to complete all required fields for the CAHPS registration marked with an asterisk. The contact will
receive important information and updates about the organization’s registration and provide next steps for administering
the CAHPS for MIPS Survey.

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You can add additional contacts by using the + Add another contact, at the bottom of the screen. As more contacts
added, the number of contacts will update in the Registration header.

As you proceed through the registration process, the Registration header will update as all changes are saved in real
time.

3. Registration Confirmation
After a contact has been added with all the required
fields, the CAHPS Registration is complete. You may
select the CAHPS For MIPS Survey Registration on the
left-hand navigation to view your completed registration.
The CAHPS Registration Status will now show as
Complete under the connected organization.
IMPORTANT: A Summary of the Group’s CAHPS
Registration will be available to download once
registration is complete, but a confirmation email will not
be provided.

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V. Modify Information for an Existing Registration
You may modify information for your existing CAHPS for MIPS Survey registration at any time during the registration
period between Monday, April 3, 2022, at 10 a.m. ET and Friday, June 30, 2023, at 8 p.m. ET.

Update Organization Size
To edit the size of your organization, select the appropriate size option from the list. The application will automatically save
the changes made.

Add, Update or Remove Contact Information
To add, update or remove contact information from your completed registration, choose to edit your group’s CAHPS
registration and make the necessary changes. The system requires at least one contact for a registration. If your
organization has one contact identified and the contact needs to be changed, you’ll need to edit the existing contact, or you
may add a new contact and delete the previous contact.

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To delete a contact, select Delete Contact.

You will be asked to confirm the deletion, please select Delete.

Add New Contact
You can add additional contacts by using the + Add another contact at the bottom of the screen. As more contacts are
added, the number of contacts will update in the Registration header.

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VI. View your CAHPS for MIPS Survey Registration Summary
You will have access to view
information about the CAHPS
for MIPS Survey registrations
for all organizations for which
you have a Security Official
role.
A summary of the CAHPS
Registration is available to be
downloaded once registration is
marked as complete. Select
Download Group CAHPS
Registration Summary from
the Registration page under the
organization.
A green checkmark indicates there is a complete registration.
A red x indicates the registration is incomplete.

No status information indicates no
registration has been started.

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On the CAHPS for MIPS Survey
Registration page, you can filter and
search by the registration status to find
the status of connected organizations
registrations.

VII. Delete Your 2023 Registration for the CAHPS for MIPS Survey
If your organization wishes to delete your completed CAHPS for MIPS Survey registration, you can log in and delete your
registration any time before the registration period closes on June 30, 2023, at 8 p.m. ET.
If you want to re-register the organization during the 2023 registration period after deleting your registration, please refer
to Section IV: Submit a New Registration of this guide.

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Delete Registration
1. Complete the steps in Section III: Access the Registration System of this guide to access your CAHPS for MIPS Survey
registration.
Select Delete Registration for the appropriate registration you wish to delete.

2. Once you select Delete Registration, you’ll be required to confirm your decision by selecting Delete to successfully
delete your registration.

When you return to the list of Connected Organizations, you should see that the
organization is no longer registered for the CAHPS for MIPS Survey.

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Note: If you didn’t intend to delete the
organization’s registration, please follow
the guidance in Section IV: Submit a
New Registration of this guide to reregister your organization before the
2023 registration period closes on June
30, 2023, at 8 p.m. ET.

VIII. For More Information
Have questions? Contact the Quality Payment Program on Monday through Friday between 8 a.m. and 8 p.m. ET:
•

Phone: 1-866-288-8292 (Customers who are hearing impaired can dial 711 to be connected to a TRS
Communications Assistant)

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Email: [email protected]

IX.

Version History

Date

Comment

06/29/2023

Corrected OMB Control Number on Page 21.

04/03/2023

Original Posting.

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