Appendix F 2024 Peer Reviewed Journal Article Requirement Template

OMB control number: 0938-134
Expiration Date: 02/28/2027
2024 MIPS Peer-Reviewed Journal Article Requirement Template
Section 101(c)(1) of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires
submission of new measures for publication in applicable specialty-appropriate, peer-reviewed journals prior to
implementing in the Merit-based Incentive Payment System (MIPS). Such measures will be submitted by the
Centers for Medicare & Medicaid Services (CMS), to a journal(s), before including any new measure on the
MIPS Quality Measures List. The measure submitter shall provide the required information for article
submission under the MACRA per the MIPS Annual Call for Quality Measures submission process.
Interested parties submitting measures for consideration through the MIPS Annual Call for Quality Measures
must complete the required information by the CMS Annual Call for Measures deadline (8 p.m. ET on May 10,
2024). Some of the information requested below may be listed in specific fields in the CMS Measures Under
Consideration (MUC) Entry/Review Information Tool (MERIT); however, to ensure that CMS has all of the
necessary information and avoid delays in the evaluation of your submission, please fully complete this form as
an attached Word document. The information in MERIT must be consistent with the information below,
including the following, but not limited to:
•
•

[Measure Title]
[Meaningful Measures 2.0 Framework Domain]
Measure Steward: [Name]
Measure Developer: [Name]
Description: [Text]

I.

Statement
• Background (Why is this measure important?).
• Environmental scan (Are there existing measures in this area?).

II.

Gap Analysis
• Provide evidence for the measure (What are the gaps and opportunities to improve care?).
• Expected outcome (patient care/patient health improvements, cost savings).
• Recommendation for the measure (Is it based on a study, consensus opinion, USPSTF
recommendation etc.?).

III.

Reliability/Validity
• What testing has been performed at the level of implementation? (MIPS requires full measure
testing at the individual clinician level (and may also need to be tested at the group level) for
MIPS Clinical Quality Measures (CQMs) and Electronic Clinical Quality Measures (eCQMs)
collection types. Administrative claims measures tested at the group level require a reliability
threshold to be implemented at the group level.)
Please provide testing results including the N value, Bonnie test case results, correlation
coefficient and any other pertinent information or values to be considered.
o
o
o
o
o
o

Reliability Testing Results at the accountable entity level
Face Validity Testing Results, Clinician Sites
Empiric Validity Testing Results at the accountable entity level
Data Element/Patient Encounter Level Testing
Exclusion Frequency
What were the minimum sample sizes used for reliability results?

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OMB control number: 0938-134
Expiration Date: 02/28/2027
•

Other Information
o Is it risk adjusted? If so, how?
o What benchmarking information is available?
o Collection Type: Specify the data collection type.
o Specify measure stage of development.
o For Patient Reported Outcome Performance Measures:
- The survey or tool has been tested and doesn’t require modifications based on
results?
- Patient/encounter level testing for each critical data element doesn’t require changes
to the tool base on the results?

IV.

Endorsement
• Provide the Consensus-Based Entity (CBE) (i.e., Partnership for Quality Measures (PQM))
endorsement status (and CBE ID) and/or other endorsing body. If the measure is only endorsed
for paper records, please note endorsement for only the data source being submitted.

V.

Summary
• Alignment with CMS Meaningful Measures Initiative or MACRA (if applicable).
• Relevance to MIPS or other CMS programs.
• Rationale: Use of measure for inclusion in program (specialty society, regional collaborative,
other).
• Public reporting (if applicable).
• Preferable relevant peer-reviewed journal for publication.
• Rationale as to how the measure correlates to existing cost measures and improvement
activities, as applicable and feasible.

According to the Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.), 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: 2/28/2027). This information collection is the tool for measure developers to submit their clinical quality measures for
consideration by CMS. The time required to complete this information collection is estimated to average 2 hours per response, including
the time to review instructions, search existing data resources, gather the data needed, to review and complete the information
collection. This information collection is voluntary and all information collected will be kept private in accordance with regulations at 45
CFR 155.260, Privacy and Security of Personally Identifiable Information.  Pursuant to this regulation, CMS may only use or disclose
personally identifiable information to the extent that such information is necessary to carry out their statutory and regulatory mandated
functions. 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, MD 21244-1850. If you have
questions or concerns regarding where to submit your documents, please contact QPP at [email protected].

Under the Privacy Act of 1974 (5 U.S.C. 552a) any personally identifying information obtained will be kept private to the extent of the
law.

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