Form CMS-10596 QE Reapplication Form

PAPER-BASED QE REAPPLICATION FORM
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 xxxx-xxxx. The time required to complete this information collection is
estimated to average 120 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. 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
support@qemedicaredata.org.
Instructions
Submit the completed QE reapplication form and supporting documents electronically to:
support@qemedicaredata.org. Submit any questions to: support@qemedicaredata.org.

Date
Reapplication
Submitted

Department of Health & Human Services
Centers for Medicare & Medicaid Services

Date
Reapplication
Received by CMS

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OMB No. xxxx-xxxx
Exp. xx/xx/xxxx

Section 1: General Information
Instructions: Please input the information for the QE. The listed QE should be the lead applicant.
Subcontractors or partners for this effort should be listed in the Member Organizations field.
Applicant’s Trade Name/DBA
Type of Applicant
Profit Organization
Non-Profit Organization
Other (describe)
Applicant’s Employer ID Number
Name(s) of Contractor(s) or Member
Organization(s)
(Contact support@QEMedicareData.org to
obtain further instructions on submitting the
required contractor or member organization
information)
Data Recipient’s Name
Data Requested
Regional (specify States)
National

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Section 2: Mailing Address
Instructions: The mailing address should be an address where mail correspondence about the
reapplication or program can be delivered.
Street Mailing Address __________________________________________________________
Suite/Mail Stop ________________________________________________________________
City _____________________________________ State ____________ ZIP Code ___________
Phone _______________________________________ Fax _____________________________
Website ______________________________________________________________________

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Section 3: Contact Information
Chief Executive Officer (or other equivalent executive)
Instructions: Please provide the contact information for the CEO, or equivalent executive, who has the
authority to oversee the entity’s reapplication and QECP responsibilities.
Prefix _______ First Name___________________________________________ Middle Initial ______
Last Name________________________________________________ Degree _________________
E-mail Address _________________________________________________________________
Street Mailing Address ___________________________________________________________
Suite/Mail Stop ________________________________________________________________
City _____________________________________ State ____________ ZIP Code ___________
Phone _______________________________________ Fax _____________________________

Point of Contact for Reapplication
Instructions: Please provide the contact information for the individual who will be the primary contact
for day-to-day reapplication and program correspondence.
Prefix _______ First Name______________________________________________ Middle Initial ______
Last Name_________________________________________________Degree ____________________
E-mail Address _________________________________________________________________
Street Mailing Address ___________________________________________________________
Suite/Mail Stop _________________________________________________________________
City _____________________________________ State ____________ ZIP Code ___________
Phone _______________________________________ Fax _____________________________

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Section 4: Standards

Instructions: Please respond to the questions for each element by checking the appropriate box (i.e.,
Yes, No, Not Applicable, etc.). When required, please provide explanations in the box labeled “QE
Explanation,” using plain language.
For certain elements, qualified entities are required to submit supporting documentation to support
their responses for the purpose of the reapplication minimum requirements review and assessment.
Please list the name of the supporting document, its relevance to the element, and the pages within the
document that demonstrate such relevance. Please refer to the 2015 QECP Operations Manual for
complete program information, specifically, Section 3.3 reapplication “evidence” requirements.

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Standard 1: Qualified Entity Profile
Element 1A: Identify changes to the QE’s organization
Question 1.1: Does your organization intend to continue to contract with the following
organizations to fulfill the QECP requirements?
List of current contractors or member organizations:
(The QE’s QECP Program
Manager pre-fills this list)



Yes
No (Provide explanation below, and submit an updated QECP Letter of
Commitment, including Attachments A–C. For each additional contractor,
submit proof of incorporation, type of organization, licensure information,
and proof of breach of contract liability with potential to collect damages
for failure to perform.)

Supporting Documentation:
Document 1
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 2
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 3
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 4
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
QE Explanation:

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Question 1.2: If your organization changed data analytics/warehousing vendors or
experienced contracting changes related to individuals/organization/vendors handling
QE Medicare data or QE Medicare data security, did your organization submit updated
Phase 2 evidence, including a new QECP Data Security Workbook?
Note: Public performance reports that include QE Medicare data must not be
disseminated using a new data analytics/warehousing vendor prior to the new vendor
(and lead QE) submitting updated QECP Phase 2 evidence and obtaining CMS approval.






Yes, we submitted updated Phase 2 evidence, including a new QECP Data
Security Workbook, and received CMS approval. (Provide explanation
below, including vendor name(s) for which evidence was submitted.)
No, we are currently in the process of submitting updated Phase 2
evidence, including a new QECP Data Security Workbook. (Provide
explanation below, including vendor name(s) for which evidence will be
submitted.)
No, we have not begun to submit updated Phase 2 evidence, including a
new QECP Data Security Workbook. (Provide explanation below, including
vendor name(s) for which evidence will be submitted.)
Not applicable—we do not anticipate contractor changes, or our
contractor changes do not involve data analytics/warehousing vendors.

QE Explanation:

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Element 1C: Identify changes in geographic area that the QE’s reports will cover
Question 1.3: Does your organization intend to maintain the following geographic
area(s) in which public performance reports will incorporate QE Medicare data?
List of current geographic areas:
(The QE’s QECP Program
Manager pre-fills this list)




Yes
No, the area has increased. (Describe below the new geographic area(s) in
which your organization intends to report using QE Medicare data.)
No, the area has decreased. (Describe below the new geographic area(s) in
which your organization intends to report using QE Medicare data.)

QE Explanation:

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Element 1D: Identify changes in the types of providers whose performance the QE
intends to assess using QE Medicare data
Question 1.4: Does your organization intend to continue to evaluate provider
performance using QE Medicare data and other data sources for the following provider
types?
List of current provider types:
(The QE’s QECP Program
Manager pre-fills this list)



Yes
No (Provide below the new list of provider types your organization
intends to evaluate using QE Medicare data.)

QE Explanation:

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Standard 2: Data Sources
Element 2A: Identify changes to the QE’s ability to obtain claims data from at least
one other payer source to combine with QE Medicare data
Question 2.1: Does your organization still receive the following sources and amounts of
other payer data for the geographic areas identified in Question 1.3 (Element 1C) and
the provider types identified in Question 1.4 (Element 1D)?
List of current data suppliers and amount of data provided:
(The QE’s QECP Program
Manager pre-fills this list)
Note: A QE may not, under any circumstances, use a measure, create a report, or issue
a report after the amount of claims data from other sources available to the QE
decreases until the QECP team determines either (1) that the remaining claims data are
sufficient or (2) that the QE has collected adequate additional data to address any
identified deficiencies.





Yes
No, the amount of other payer data received by our organization has
increased. (Submit a new QECP Data Source Attestation.)
No, the amount of other payer data received by our organization has
decreased. (Submit a new QECP Data Source Attestation. Provide an
explanation below, by data supplier name, of the reason that the data
source is no longer available to your organization, or the reason that
the amount of data received by the supplier has decreased. Submit
documentation demonstrating that the remaining claims data from
other sources are sufficient to address methodological concerns
regarding sample size and reliability.)

QE Explanation:

Supporting Documentation:
Document 1
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Document 2
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 3
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 4
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Standard 3: Data Security
Standard 3: Identify changes to the QE’s data security and privacy policies and
procedures
Question 3.1: Does the annotated physical network diagram submitted by your
organization still accurately demonstrate (1) how sites that access the QE Medicare data
are connected, and (2) how QE Medicare data flow through your organization from
receipt to public reporting (including the confidential provider corrections and appeals
process)? This includes Internet, wide area network, local area network, and virtual
private network connections.
Current Annotated Physical Network/QE Data Flow Diagram:
(The QE’s QECP Program
Manager uploads this diagram)




Yes
No (Submit an updated annotated physical network/QE data flow diagram.
Refer to Questions 1.1 and 1.2 for requirements related to changes in
contractual relationships with data analytics/warehousing vendors.)

Supporting Documentation:
Document 1
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 2
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Question 3.2: Since Phase 2 approval, or submission of your organization’s most recent
QECP Annual Report, has your organization experienced major changes to data security
and privacy policies and procedures?
A “change” includes:










changes to the physical location of CMS data;
assignment of a new information technology contractor;
changes to alternative storage and processing sites, or disposal of IT
equipment that stored CMS data;
changes to configuration management;
assignment of primary security responsibility to a new individual;
changes in ownership or management structure;
changes in contractors;
and changes in state privacy and security laws.




Yes (Describe below the changes, including dates when each change
occurred.)
No

QE Explanation:

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Standards 4 and 5: Measure Selection and Methodology for Measurement and Attribution
Elements 4A and 5A–5J: Identify changes to standard measures the QE intends to
report in its next public reporting cycle
Question 4.1: Does your organization intend to continue reporting the following
standard measures in its next public reporting cycle?
List of current standard measures:
(The QE’s QECP Program
Manager pre-fills this list)

Note: QEs are required to notify the QECP team of any new standard measures it wishes
to add to its approved list of measures at least 30 days before its intended confidential
performance release to providers for the correction and appeal process.
 Yes
 No (Provide an explanation of the standard measures that will be
added or removed in your organization’s next public reporting cycle.
For measures that will be added, submit a revised QECP Measure
Information Workbook, accompanied by the required supporting
documentation for Elements 4A and 5A-5J.
QE Explanation:

Supporting Documentation:
Document 1
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 2
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 3
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Exp. xx/xx/xxxx

Elements 4B and 5A–5J: Identify changes to alternative measures the QE intends to
report in its next public reporting cycle
Question 5.1: Does your organization intend to continue reporting the following
alternative measures in its next public reporting cycle?
List of current alternative measures:
(The QE’s QECP Program
Manager pre-fills this list)
Note: QEs are required to notify the QECP team of any alternative measures they wish
to add to their approved list of measures. QEs are strongly encouraged to notify the
QECP team of any new alternative measures at least 90 days before the intended
confidential performance report release to providers.
 Yes
 No (Provide an explanation of the alternative measures that will be
added or removed in your organization’s next public reporting cycle.
For measures that will be added, submit a revised QECP Measure
Information Workbook, accompanied by the required supporting
documentation for Elements 4B and 5A–5J.
QE Explanation:

Supporting Documentation:
Document 1
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 2
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 3
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Standard 6: Verification Process
Element 6A: Identify changes to the QE’s process for systematically evaluating the
accuracy of its calculation of performance measures
Question 6.1: Referring to the QECP Measure Production Quality Assurance (QA)
Worksheet submitted during your organization’s Phase 3 application as a baseline, has
your organization experienced any changes to its internal verification process, audit
process, or software used to evaluate the accuracy of calculating performance measures
that include QE Medicare data?
Current QECP Measure Production Quality Assurance (QA) Worksheet:
(The QE's QECP Program Manager
uploads this diagram)
 Yes (Provide and explanation of the changes and submit and updated
QECP Measure Production QA Worksheet.)
 No
QE Explanation:

Supporting Documentation:
Document 1
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 2
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Standard 7: Reporting of Performance Information

Element 7A: Identify changes in the design of reports for providers and the public
Question 7.1: Does your organization anticipate changes in the appearance or content
of its provider or public report during its next reporting cycle? A “change” is defined as a
significant modification in provider ratings approach, the level of analysis for reported
measures, comparative reporting by product line, or website address, for example, but
excludes changes due to the addition or removal of performance measures.
Note: QEs must notify the QECP team of changes to the provider or the public report
prototype report and submit to the QECP team the new prototype report at least 30
days before its intended confidential release.
 Yes (Provide an explanation of the changes below, and submit the
revised provider and/or public report prototype.)
 No
QE Explanation:

Supporting Documentation:
Document 1
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________
Document 2
Document Name: _________________________________________________
Document Relevance: ______________________________________________
Relevant Pages: ___________________________________________________

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Question 7.2: Referring to the dissemination plan your organization submitted during
its Phase 3 application, does your organization anticipate any changes to its
dissemination plan for informing intended audiences of the issuance of its QE
performance reports? This includes anticipated changes to the public report release
schedule and frequency.
Current Provider and Public Report Dissemination Plan:
(The QE's QECP Program Manager
uploads this diagram)
Note: QEs must notify the QECP team of changes in the dissemination plan for sharing
reports with the public and submit the new plans at least 30 days before the intended
confidential performance report release to providers.
 Yes (Provide an explanation of the changes below.)
 No
QE Explanation:

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Standard 8: Requests for Corrections and Appeals
Element 8A and 8B: Identify changes to the corrections process; identify any changes
related to the secure transmission of beneficiary data
Question 8.1: Referring to the confidential provider corrections and appeals process
your organization submitted during its Phase 3 application, does your organization
anticipate any changes to this process prior to its next reporting cycle? This includes any
changes to your organization’s privacy and security protections for the release of
beneficiary identifiers and/or claims data to providers.
 Yes (Provide an explanation of the changes below. These changes
must be reflected in the physical network/QE data flow diagram
provided under Question 3.1. Changes related to contractual
relationships with data analytics/warehousing vendors are subject to
the requirements of Questions 1.1 and 1.2.)
 No
QE Explanation:

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Section 5: Attestation
Instructions: Prior to a reapplication being submitted as final, the contents of the reapplication must be
accompanied with a completed attestation from an individual at the entity authorized to attest to its
accuracy and completion.
To the best of my knowledge and belief, all data in this reapplication are true and correct, the document
has been duly authorized by the governing body of the reapplicant, and the reapplicant will comply with
the terms and conditions of the award and applicable Federal requirements awarded.

Authorized Representative’s Name (printed) _________________________________________

Authorized Representative’s Title (printed) __________________________________________

Signature_____________________________________________ Date ____________________

Phone _______________________________________ Fax _____________________________

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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Section 6: Additional Supporting Documentation
Instructions: Please describe all additional supporting documentation submitted in conjunction with this
reapplication that is not listed in Section 4.
1.

Standard:
_____________
Element:
_____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

2.

Standard:
_____________
Element:
_____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

3.

Standard:
_____________
Element:
_____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

4.

Standard:
_____________
Element:
_____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

5.

Standard:
_____________
Element:
_____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

6.

Standard:
_____________
Element:
_____________
Document Name: _______________________________________________________
Document Relevance: ____________________________________________________
Relevant Pages: _________________________________________________________

Department of Health & Human Services
Centers for Medicare & Medicaid Services

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