Qualified Registry Self Nomination Fact Sheet

Quality Payment Program

Qualified Registry Tips:
How to Self-Nominate and to Submit Data
Overview
To become a qualified registry for the Merit-based Incentive Payment System (MIPS), you must selfnominate.

When can I self-nominate?
You can self-nominate from:


November 15, 2016 – January 15, 2017, for the 2017 performance period



September 1 – November 1 of the prior year, beginning with the 2018 performance period

What’s a Qualified Registry?
A qualified registry is an entity that collects clinical data from an individual MIPS clinician or group
practice and submits it to CMS on behalf of the clinicians. Clinicians work directly with their chosen
registry to submit data on the selected measures or specialty set of measures.

How do I become a Qualified Registry?
By self-nominating and successfully completing a qualification process.

Requirements:
1. Participants: You must have at least 25 participants by January 1, 2017. These participants don’t
necessarily need to be using the qualified registry to report MIPS data to us, but they need to be
submitting data to the qualified registry for quality improvement.
2. Attestation Statement: You must provide a statement during the data submission period verifying
that all of the data (quality measures, improvement activities, and advancing care information
measure and objectives, if applicable) and results are accurate and complete.
3. Data Submission: You must submit data via a CMS-specified secure method for data submission,
such as a defined XML file.
4. Data Validation Report: You must provide information on your process for data validation for both
individual MIPS eligible clinicians and groups within a data validation plan. Results of the executed
data validation plan must be provided by May 31 of the year following the performance period.

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Information Required
You must provide the following when you self-nominate:
 Organization Name
 MIPS Performance Categories
 Performance Period

 Method for Calculating Performance Rates
for Quality Measures (source of clinician’s
data)

 Data Capture Methods

 Method for Calculating Performance Data for
Improvement Activities and Advancing Care
Information (source of clinician’s data)

 Method for Verifying TINs and NPIs

 Randomized Audit Process

 Vendor Type

 Data Validation Process
 Data Validation Results

Data Submission
A qualified registry must perform the following functions related to submitting data:
1. Indicate:
 CEHRT data source
 Whether you are reporting on advancing care information measures and objectives
 Performance period start and end dates
2. Submit:
 Data and results for all your MIPS performance categories
 Include data on all patients, not just Medicare patients
 Separate reports on all payers, including Medicare Part B FFS and non-Medicare
 Results for at least 6 quality measures, with at least 1 outcome measure
 If outcome measures are not available, use at least 1 other high-priority measure
 Measure numbers for quality measures
 Measure titles for quality measures and improvement activities
 Measure-level reporting rates by TIN/NPI and/or TIN
 Performance rates by TIN/NPI and/or TIN

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 Risk-adjusted results for any risk-adjusted measures
 Sampling methodology
 Performance categories feedback at least 4 times a year for all MIPS-eligible clinicians
3. Report on the number of:
 Eligible instances (reporting denominator)
 Times a quality service is performed (performance numerator)
 Performance exclusions
 Times the applicable submission criteria were not met
4. Verify and maintain eligible clinician information:
 Signed verification of clinician names, contact information, costs charged to clinicians, services
provided, and specialty-specific measure sets
 Business agreement(s) with clinicians or groups who provide patient-specific data
 Include disclosure of quality measure results and data on Medicare and non-Medicare
beneficiaries
 Signed NPI-holder authorization to:
 Submit results and data to CMS for MIPS
 Release email address for feedback report distribution
 Attestations that all data and results are accurate and complete
5. Comply with:
 Any request for CMS to review your submitted data
 Requirements for joining CMS conference calls and in-person kick-off meeting
 CMS-approved secure method for data submission
 An XML file, for example
If any data inaccuracies affect more than 3% of your total MIPS-eligible clinicians, you:


Might receive a low data quality rating on our qualified registry listing



Will be placed on probation

Data inaccuracies affecting more than 5% of your total MIPS-eligible clinicians may lead to
disqualification for the following year.

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Survey Vendor Requirements
To be CMS-approved, a survey vendor for CAHPS for MIPS must agree to:
1. Participate in training sessions
2. Comply with:
 Vendor Participation Form (to be completed by vendor)
 Minimum Survey Vendor Business Requirements
 All protocols and specifications

Tips for Successful Self-Nomination:
1. To become qualified for a given performance period, the entity must be in existence as of January 1 of
the performance period. For example, to be eligible in the 2017 performance period, the entity must
be in existence by January 1, 2017.
2. You’re required to provide all information at the time of self-nomination, via Jira
https://oncprojectracking.healthit.gov/support/login.jsp, to make sure you meet the self-nomination
requirements.
3. Self-nomination is an annual process. If you want to qualify as a registry, you’ll need to self-nominate
for that year. Just because you qualified as a in a prior year, it doesn’t mean you’ll automatically
qualify in subsequent performance periods.
The list of entities that have been qualified to submit data to CMS as a qualified registry for purposes of
MIPS will be posted on a QPP.cms.gov.

Resources







Qualified Registry Support Calls – We’ll hold mandatory support calls approximately once a
month. The support calls address reporting requirements, steps for successful submission, and a
question and answer session. An in-person kick-off meeting in Baltimore (if held) is also a
requirement. Sign up for CMS email updates to receive more information.
Quality Payment Program Portal - Educational documents for qualified registry participation will
be available on the portal to help support you in your submission process.
Quality Payment Program Service Center - If you have questions, the Quality Payment Program
Service Center will be able to direct your call to the appropriate staff to best meet your needs. You
can reach the Quality Payment Program Service Center at 1-866-288-8292 or 1-877-715-6222 (TTY).
The Self-Nomination Implementation Guide- This guide provides step-by-step instructions for
entities looking to become CMS approved for the 2017 program year.

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