OMB control number

Application To Be a Qualified Entity to Receive Medicare Data for Performance Measurement / Reapplication / Annual Report Worksheet (CMS-10394)

OMB 0938-1144 · HHS/CMS.

OMB 0938-1144

Section 10332 of the Patient Protection and Affordable Care Act (ACA) requires the Secretary to make standardized extracts of Medicare claims data under Parts A, B, and D available to ''qualified entities'' for the evaluation of the performance of providers of services and suppliers. The statute provides the Secretary with discretion to establish criteria to determine whether an entity is qualified to use claims data to evaluate the performance of providers of services and suppliers. We are proposing at section CFR 401.703 to evaluate an organization's eligibility across three areas: organizational and governance capabilities, addition of claims data from other sources (as required in the statute), and data privacy and security. This is the application through which organizations will provide information to CMS to determine whether they will be approved as a qualified entity.

The latest form for Application To Be a Qualified Entity to Receive Medicare Data for Performance Measurement / Reapplication / Annual Report Worksheet (CMS-10394) expires 2027-07-31 and is listed under ICR 202404-0938-006.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form CMS-10394 QECP Data Source Attestation WorkbookForm and Instruction
Form CMS-10394 Public Report Submission FormForm and Instruction
Form CMS-10394 Extension Request LetterForm and Instruction
Form CMS-10394 Letter of Commitment TemplateForm and Instruction
Form CMS-10394 Qualified Entity Certification Program Data Security Review (QECP DSR)Form and Instruction
Form CMS-10394 Phase 3 Application Readiness ChecklistForm and Instruction
Form CMS-10394 Phase 2 Application Readiness ChecklistForm and Instruction
Form CMS-10394 Phase 1 Application Readiness ChecklistForm and Instruction
Form CMS-10394 QECP Paper-Based Reapplication FormForm and Instruction
CMS10394 QECP Supporting Statement Part A.docxSupporting Statement A
Nakul Karkare.pdfPublic Comments
FIRN_CMS-10394_Comment.docxPublic Comments
Response to Public Comments.docxSupplementary Document
QECP-SUPP-PRAIns-Chngs-V3 1-24_2026.docxSupplementary Document
QECP Application, Reapplication, DUA and ARW Form and Instruction
QECP Application, Reapplication, DUA and ARW Form and Instruction
QECP Application, Reapplication, DUA and ARW Form and Instruction
QECP Application, Reapplication, DUA and ARW Form and Instruction
QECP Application, Reapplication, DUA and ARW Form and Instruction
QECP Application, Reapplication, DUA and ARW Form and Instruction
QECP Application, Reapplication, DUA and ARW Form and Instruction
QECP Application, Reapplication, DUA and ARW Form and Instruction
QECP Application, Reapplication, DUA and ARW Form and Instruction
QECP Application, Reapplication, DUA and ARW Instruction

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