Appendix D1 2024 Submission Form for Requests for Qualifying Alterna

1

CMS Quality Payment Program
Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP)
Determinations under the All-Payer Combination Option
(All-Payer QP Submission Form)

Welcome to the All-Payer QP Submission Form
Purpose
The All-Payer QP Submission Form (Form) may be used to request that CMS determine whether
Eligible Clinicians are QPs under the All-Payer Combination Option of the Quality Payment
Program (QPP) as set forth in 42 CFR 414.1425. This process is called the QP Determination
Process. More information about QPP is available at http://qpp.cms.gov/.
The All-Payer Combination Option covers Eligible Clinicians, TINs, and APM Entities whose
Medicare fee-for-service (FFS) QP threshold scores under the Medicare Option meet or exceed a
certain minimum, but do not meet or exceed the threshold scores required to achieve QP status
under the Medicare Option for a given year. This Form collects payment amount and patient
count information on payers other than Medicare FFS, for purposes of calculating payment
amount and patient count threshold scores under the All Payer Combination Option.
The charts below display the minimum Medicare FFS QP threshold scores and All-Payer
Combination Option threshold scores that would make an Eligible Clinician, TIN, or APM
Entity a QP or Partial QP under the All-Payer Combination Option.
Payment Amount Threshold Scores
Performance Year

2023 and beyond
Total

QP Payment Amount Threshold

75%

2023 and beyond
Medicare
Minimum
25%

Partial QP Payment Amount Threshold

50%

20%

Performance Year

2023 and beyond
Total

QP Patient Count Threshold

50%

2023 and beyond
Medicare
Minimum
20%

Partial QP Patient Count Threshold

35%

10%

Patient Count Threshold Scores

2
Eligible Clinicians, APM Entities, and TINs that meet neither the minimum payment amount nor
the minimum patient count Medicare FFS threshold scores will not be evaluated for QP status
under the All-Payer Combination Option. Clinicians who meet or exceed the Medicare FFS QP
threshold scores using either the payment amount or the patient count methodology do not need
the All-Payer Combination Option, as they are already QPs under the Medicare Option.
Additional Information
Because CMS has access to Medicare FFS claims data, [Eligible Clinicians/ TINs/ APM
Entities] should not include Medicare FFS payments or patients in this Form. Information must
be submitted for each other payer from which the [Eligible Clinician/Eligible Clinicians
participating in the TIN/Eligible Clinicians participating in the APM Entity] received payments
for services provided during the Performance Period, with the exception of the following payers:
1) The Secretary of Defense for the costs of Department of Defense health care
programs;
2) The Secretary of Veterans Affairs for the cost of Department of Veterans Affairs
health care programs; and
3) Title XIX, if the Eligible Clinician, TIN, or APM Entity meets the criteria to have
Title XIX payments and patients excluded from threshold score calculations.
Eligible Clinicians, TINs, or APM Entities whose primary practice is in any of the
following locations, are required to submit their Title XIX payments and patient
data. Eligible Clinicians, TINs, and APM Entities may exclude their Title XIX
payment and patient data.
XIX Table:
State of Primary Practice
Massachusetts
Ohio
Tennessee
Washington

County of Primary Practice
All Counties
All Counties
All Counties
All Counties

A single patient may be included under the numerator and/or denominator for multiple payers.
For example, a patient whose primary insurance is a Medicare Advantage plan and whose
secondary insurance is Medicaid should be included under both the Medicare Advantage plan
and the Medicaid plan.

Notification
CMS will include the list of all Eligible Clinicians determined to be QPs for the QP Performance
Period in a look-up tool on a CMS website.
Helpful Links:
- QPP All-Payer QP Submission Form User Guide

3
- Glossary
All Forms must be completed and submitted electronically.
This Form contains the following sections:
Section 1: Submitter Type
Section 2: Participant Identifying Information
Section 3: Other Payer Advanced APM Participation Data
Section 4: Certification Statement

4

SECTION 1: Submitter Type
Select one of the following:
1. APM Entity [CHECK BOX]
APM Entity means an entity that participates in an APM or payment arrangement
with a non-Medicare payer through a direct agreement or through Federal or State
law or regulation.
2. Eligible Clinician(s) [CHECK BOX]
Eligible clinician means "eligible professional" as defined in section 1848(k)(3) of the
Act, as identified by a unique TIN and NPI combination and, includes any of the
following:
---I. A physician.
---ii. A practitioner described in section 1842(b)(18)(C) of the Act.
---iii. A physical or occupational therapist or a qualified speech-language
pathologist.
---iv. A qualified audiologist (as defined in section 1861(ll)(3)(B) of the Act).
3. TIN Level [CHECK BOX]
The representative who submits the Form for the TIN must be an authorized agent of
the TIN. In submitting the Form, the submitter attests that he or she is qualified to
make the assertions contained herein as an agent of the TIN and that the assertions
contained herein are true and accurate with respect to this Form.

SECTION 2: Participant [Eligible Clinician/TIN/APM Entity] Identifying
Information
A.

Point of Contact for this Form
1. Name:________________________
2. Job Title:_________________________
3. Organization Name:______________________
4. Email:__________________________
5. Confirm Email:__________________________
6. Business Phone Number:__________________________
Ext:____________________
7. Address Line 1 (Street Name and Number): ___________________________
Address Line 2 (Suite, Room, etc.): _________________________
City: ________________ State: _____ Zip Code +4: ____________

5

B.

[If Eligible Clinician] Eligible Clinician Information
If an authorized representative is submitting information on behalf of multiple Eligible
Clinicians, that authorized representative must complete this form separately for each
Eligible Clinician.
1. Name of Eligible Clinician: ________________________
2. TIN(s) under which Eligible Clinician bills :______________________
3. Eligible Clinician’s NPI:__________________________
4. Confirm NPI: __________________________________
[If TIN] TIN Information
1.

TIN Legal Entity Name:_______________________

2. Tax Identification Number: __________________________
3. Retype TIN:______________________________
[If APM Entity] APM Entity Information
1. Name of APM Entity:_______________________
2. All TIN(s) through which all NPIs in the APM Entity bill:_________________
3. Retype TINs:_______________________________________________
Note: CMS will use its internal records to determine the list of NPIs that participated in
this APM Entity during the Performance Period.

SECTION 3: Other Payer Advanced APM Participation Data
Per statute, information for all payers through which the [Eligible Clinician/TIN/Eligible
Clinicians participating in the APM Entity] bills/bill must be included, with the exceptions of
Department of Defense health care programs, Department of Veterans Affairs health care
programs and Title XIX if the [Eligible Clinician/ TIN/ APM Entity] meets Title XIX exclusion
criteria. Information on Medicare FFS or participation in Medicare Advanced APMs should not
be submitted.
Eligible Clinicians, TINs, and APM Entities must choose a specific Snapshot Period for
submitting data. This period must match the same timeframe for the Medicare Advanced APM in
which you participate. In order to have a QP determination made for a Snapshot Period, you
must enter information for every payer for that Snapshot Period.

6
Please note that CMS may validate your Other Payer Advanced APM participation information
with the payers you include in this Form.
Snapshot Period
Please select the Snapshot Period for which you are submitting data for the 2024 QP
Performance Period. Note, this Snapshot Period should be the same as the Medicare FFS
Snapshot Period data you choose to be used in the All-Payer QP Calculation. If you have not
achieved QP status based on any Medicare snapshot, we will assess your performance using the
All-Payer Combination Option base on the snapshot you select:
[Drop down menu]
1. January – March
2. January – June
3. January – August
Work Sheet for Data Submission
[Instructions provided for downloading and uploading an Excel Spreadsheet for entering
required data. Users will enter the information for each payment arrangement with each payer or
discreate plan from which they have received payment for serviced during the snapshot period
selected.]
In the Participant Identification section of the QPP All Payer Submission Form, you selected whether
your submission is at the APM Entity, Eligible Clinician, or TIN level. In Section [#], you indicated the
“Snapshot Period” for which you are submitting data. Data reported in this worksheet MUST be
reported at the level you indicated in the “Submitter Type” field and for the “Snapshot Period” you
indicated in Section [#]. For example, if you selected “TIN level” as your submitter type and the “Second
Snapshot” as the period for which you are submitting data, please enter in all payment arrangements
under which your TIN received payments during the Second Snapshot (January 1, 2024-June 30, 2024).
This form may be completed by [the eligible clinician/an eligible clinician in your TIN/an eligible
clinician in your APM Entity] or by an authorized individual on behalf of the [eligible clinician/TIN/APM
Entity. Examples of authorized individuals include (but are not limited to) practice manager, financial
analyst/ manager, and accountant.
Note: The TIN reporting option may only be used by TINs participating in the Medicare Shared Savings
Program.

7
The following information must be submitted in each row of the worksheet for which an
entry is made:
A. Payment Arrangement Name [Drop down list of previously determined Other Payer
Advanced APMs; or free text]:___________________________
B. Payment Arrangement Identifier [drop-down: Identifiers of previously determined
Other Payer Advanced APMs; or free text] _____________________________
C. Payer Name:______________________________
D. Type of Payer (e.g., Medicare Advantage, Medicaid):_________________________
E. Payment Arrangement Point of Contact Name:_____________________________
F. Payment Arrangement Point of Contact Phone: ______________________________
G. Total Payments:____________________________________________________
Enter the total payments received (in dollars) under the terms of the payment
arrangement you entered in column A. The data entered into this field should be based on
the "Snapshot Period" you selected in Section [#] of the QPP All Payer Submission Form
and at the same level as the Participant Identification you selected in the QPP All Payer
Submission Form. For example, if you indicated in the QPP All Payer Submission Form
that your submission was for the Second Snapshot and your Submitter Type was “TIN
level,” the dollar amount you enter in this field should be the total payments that the TIN
received under the payment arrangement during the Second Snapshot (January 1, 2024June 30, 2024).
Drug costs should be included in the reported total payments IF the payment
arrangement includes drug costs. If drug costs are not included in the payment
arrangement, drug costs should not be reported as part of total payments.
H. Total Patients:____________________________________________________
On the Data Collection Worksheet tab, enter the number of unique patients furnished
services under the terms of the payment arrangement you entered in column A. The data
entered into this field should be based on the "Snapshot Period" you selected in Section
[#] of the QPP All Payer Submission Form and at the same level as the “Submitter
Type” you selected in the QPP All Payer Submission Form. For example, if you indicated
in the QPP All Payer Submission Form that your submission was for the Second
Snapshot and your Submitter Type was “TIN level,” the number you enter in this field
should be the total number of unique patients to whom the TIN furnished services under
the payment arrangement during the Second Snapshot (January 1, 2024-June 30, 2024).

8
To determine which patients should be counted, please include only those that are
included in the measure of total payments you reported for the payment arrangement.
Note that this is a count of unique patients NOT a count of unique visits (i.e., one patient
with two visits under the same payment arrangement will be counted only once.)

SECTION 4: Certification Statement
I have read the contents of this submission. By submitting this Form, I certify that I am legally
authorized to bind the [Eligible Clinician/TIN/APM Entity]. I further certify that the information
contained herein is true, accurate, and complete, and I authorize the Centers for Medicare &
Medicaid Services (CMS) to verify this information. If I become aware that any information in
this Form is not true, accurate, or complete, I will notify CMS of this fact immediately. I
understand that any person who knowingly files a statement of claim containing any false,
incomplete, or misleading information, may be guilty of a criminal act punishable under Federal
and state law and may be subject to civil penalties.
I agree [Check box]
AUTHORIZED INDIVIDUAL NAME, TITLE, [ELIGIBLE CLINICIAN/TIN/APM ENTITY
NAME]

9

QP Submission Form Privacy Act Statement
The Centers for Medicare & Medicaid Services (CMS) is authorized to collect the information
requested on this Form by sections 1833(z)(2)(B)(ii) and (z)(2)(C)(ii) of the Social Security Act
(42 U.S.C. 1395l).
The purpose of collecting this information is to determine whether the [Eligible
Clinician/Eligible Clinicians participating in the Advanced APM] [is/are] [a QP/QPs] as set forth
in 42 C.F.R. 414.1425 for the relevant All-Payer QP Performance Period.
The information in this request will be disclosed according to the routine uses described below.
Information from these systems may be disclosed under specific circumstances to:
1. CMS contractors to carry out Medicare functions, collating or analyzing data, or to detect
fraud and abuse;
2. A congressional office in response to a subpoena;
3. To the Department of Justice or an adjudicative body when the agency, an agency
employee, or the United States Government is party to litigation and the use of the
information is compatible with the purpose for which the agency collected the
information;
4. To the Department of Justice for investigating and prosecuting violations of the Social
Security Act, to which criminal penalties are attached.
Protection of Proprietary Information
Privileged or confidential commercial or financial information collected in this Form is protected
from public disclosure by Federal law 5 U.S.C. 552(b)(4) and Executive Order 12600.
Protection of Confidential Commercial and/or Sensitive Personal Information
If any information within this request (or attachments thereto) constitutes a trade secret or
privileged or confidential information (as such terms are interpreted under the Freedom of
Information Act and applicable case law), or is of a highly sensitive personal nature such that
disclosure would constitute a clearly unwarranted invasion of the personal privacy of one or
more persons, then such information will be protected from release by CMS under 5 U.S.C.
552(b)(4) and/or (b)(6), respectively.

10
PRA Disclosure Statement
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 5 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].