QCDR Self Nomination Fact Sheet

Quality Payment Program

Qualified Clinical Data Registry
(QCDR) Tips:
How to Self-Nominate and Submit Data
Overview
To become a qualified clinical data registry (QCDR) for the Merit-based Incentive Payment System (MIPS)
under the Quality Payment Program, you must self-nominate.
When can I self-nominate?


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

Please note that QCDRs cannot be owned or managed by an individual locally-owned specialty group.

What’s a QCDR?
A QCDR is a CMS-approved entity that collects clinical data on behalf of clinicians for data submission.
Examples include, but aren’t limited to, regional collaboratives and specialty societies. QCDRs can’t be
owned or managed by an individual, locally-owned specialty group.
The QCDR reporting option is different from a qualified registry because it isn’t limited to measures
within the Quality Payment Program. The QCDR can host “non-MIPS” measures approved by CMS for
reporting. Measures submitted by a QCDR may include measures from one or more of the following
categories, with a maximum of 30 non-MIPS measures allowed per QCDR:


Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CAHPS), which must
be reported via CAHPS certified vendor



National Quality Forum (NQF) endorsed measures



Current 2017 MIPS measures



Measures used by boards or specialty societies



Measures used by regional quality collaborations



Other approved CMS measures

1

Quality Payment Program

How do I become a QCDR?
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 need
to be using the QCDR to report MIPS data to us, but they need to be submitting data to the QCDR for
quality improvement.
2. Attestation Statement: A statement from the QCDR must be provided 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. Once we
post the QCDR on our Web site, including the services offered by the QCDR, we will require the QCDR
to support these services or measures for its clients as a condition of your qualification as a QCDR for
purposes of MIPS. Failure to do so will prevent the QCDR from participation in MIPS in the subsequent
year.
3. Data Submission: You must submit data via a CMS-specified secure method for data submission,
such as a QRDA or 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 reporting period.

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

 Performance Period

 Method for Calculating Performance Data for
Improvement Activities and Advancing Care
Information (how the QCDR gets/collects the
data from the clinician)

 Vendor Type

 Randomized Audit Process

 Data Capture Methods

 Data Validation Process

 Method for Verifying TINs and NPIs

 Data Validation Results

 Method for Calculating Performance Rates
for Quality Measures (how the QCDR
gets/collects the data from the clinician)

 Risk Adjustment Method for Non-Program
Quality Measures

 MIPS Performance Categories

2

Quality Payment Program

Data Submission
A QCDR must perform the following functions related to submitting data:
1. Indicate:
 CEHRT data source
 Performance period start and end dates
 Whether you are reporting on advancing care information measures and objectives
2. Submit:
 Data and results for all your MIPS performance categories
 Include data on all patients, not just Medicare patients
 Results for at least 6 quality measures, including 1 outcome measure
 If an outcome measure is not available, use at least 1 other high priority measure
 Give entire distribution of measure results by decile, if available
 Separate reports on all payers, including Medicare Part B FFS and non-Medicare
 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
 Performance categories feedback at least 4 times a year for all MIPS-eligible physicians
 Sampling methodology
 Risk-adjusted results for any risk-adjusted measures
 Details for non-program measures:
 Data elements and measure specifications
 Risk-adjusted results for non-program quality data
 Comparison of quality of care by measure, by clinician or group
 Data from before the start of the performance period, if available
 All Quality Payment Program and non-program measures to CMS on a designated webpage
 Include specifications for non-MIPS measures
3

Quality Payment Program

3. Report on the number of:
 Eligible instances (reporting denominator)
 Times a quality service is performed (performance numerator)
 Times the applicable submission criteria were not met.
 Performance exclusions
 You can also report on up to 30 non-MIPS quality measures, if desired
4. Verify and maintain eligible clinician information:
 Signed verification of clinician names, contact information, services provided, costs charged to
clinicians, and measures 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 data and results to CMS for Quality Payment Program
 Release email address for feedback report distribution
 Attestations that all data and results are accurate and complete
5. Comply with:
 Any CMS request to review your submitted data
 Requirements to participate in CMS conference calls and in-person kick-off meeting
 A 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 website’s QCDR 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.

4

Quality Payment Program

Measure Specifications
You must provide specifications for each measure, activity, or objective that you intend to submit:


Provide descriptions and narrative specifications for each measure, activity, or objective no later than
January 15 of the applicable performance period. Beginning with the 2018 performance period, those
specifications must be provided no later than November 1 prior to the applicable performance
period.



Publicly post the measure specifications for each non-program quality measure no later than 15 days
following our approval of these measure specifications, and provide us the link to where this
information is posted.
For quality measures not included in the
Quality Payment Program, quality measure
specifications must include:


Name or title of measures



NQF number, if applicable



Descriptions of the denominator and
numerator



Descriptions of the denominator exceptions,
denominator exclusions, risk adjustment
variables, and risk adjustment algorithms,
when applicable

For Quality Payment Program measures, you
only need to submit the MIPS measure numbers
and the specialty-specific measure sets.

Non-MIPS Quality Measures
The following are non-Quality Payment Program quality measures:


A measure that isn’t contained in the annual list of Quality Payment Program measures for the
applicable performance period.



A measure that may be in the annual list of Quality Payment Program measures but has substantive
differences in the manner it’s submitted by the QCDR.



The CAHPS for MIPS survey, which can only be submitted using a CMS-approved survey vendor.

5

Quality Payment Program

Collaboration to Become a QCDR
You can become a QCDR through collaboration if you don’t meet the criteria of a QCDR on your own, but
could do so with another entity.
An entity that uses an external organization for data collection, calculation, or transmission may meet the
definition of a QCDR if the entity has a signed, written agreement that specifically details the relationship
of the entity with the external organization. This agreement must be effective as of September 1 prior to
the performance period.

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 Web site maintained by CMS.

Resources







QCDR 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 QCDR participation will be
available on the portal to help support you in your submission process.
Quality Payment Program Service Center - If you have any 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 1-877715-6222 (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.

6