CMS Quality Payment Program
Submission Form for Other Payer Requests for Other Payer Advanced APM Determinations (Payer Initiated Submission Form)
Purpose
The Payer Initiated Submission Form (Form) may be used by State Medicaid programs, Medicare Health Plans (including Medicare Advantage, Medicare-Medicaid Plans, 1876 and 1833 Cost Plans, and Programs of All Inclusive Care for the Elderly (PACE) plans), or commercial or other private payers with payment arrangements in a CMS Multi-Payer Model to request that CMS determine whether such payment arrangements are Other Payer Advanced APMs under the Quality Payment Program as set forth in 42 CFR § 414.1420. This process is called the Payer Initiated Other Payer Advanced APM Determination Process (Payer Initiated Process). More information about the Quality Payment Program is available at http://qpp.cms.gov/.
Deadlines
Submission Deadlines are specific to payer type.
State Medicaid programs requesting a determination for any payment arrangement under Title XIX of the Social Security Act, including payment arrangements aligned with a CMS Multi-Payer Model, must submit this Form by April 30 of the year prior to relevant All-Payer QP Performance Period.
Medicare Health Plans requesting a determination for a payment arrangement, including one aligned with a CMS Multi-Payer Model, must submit this Form by the annual Medicare Advantage bid submission deadline of the year prior to relevant All-Payer QP Performance Period.
Commercial or other private payers requesting a determination for a payment arrangement aligned with a CMS Multi-Payer Model must submit this Form by June 30 of the year prior to relevant All-Payer QP Performance Period.
CMS will not review Forms submitted after the applicable Submission Deadline.
Different payment arrangements under the same payer or state must be submitted separately. Payers and states must submit the required information pertaining to each payment arrangement they wish to have reviewed.
Additional Information
CMS will review the payment arrangement information in this Form to determine whether the payment arrangement meets the Other Payer Advanced Alternative Payment Model (APM) criteria. If a payer or state submits incomplete information and/or more information is required to make a determination, CMS will notify the payer or state and request the additional information that is needed. Payers and states must return the requested information no later than 10 business days from the notification date. If the payer or state does not submit sufficient information within this time period, CMS will not make a determination regarding the payment arrangement. As a result, the payment arrangement would not be considered an Other Payer Advanced APM for the year. These determinations are final and not subject to reconsideration.
Notification
CMS will notify the payer or state regarding determinations as soon as practicable after applicable Submission Deadline. CMS will also post a list of all the payment arrangements determined to be Other Payer Advanced APMs on a CMS website.
Instructions for Completing and Submitting this Form
All Forms must be completed and submitted electronically. Additional information for submission by payer type will be disseminated following publication of the CY 2018 Quality Payment Program Final Rule. Note that, if the submission mechanism for a given payer type, such as the Health Plan Management System (HPMS), already collects the data points listed in a section of the Submission Form, CMS will make reasonable efforts to ensure that there is no need for the payer to duplicate the entry of such data.
This Form contains the following sections:
Section 1: Payer Identifying Information
Section 2: Payment Arrangement Information
Section 2.1: Title XIX (Medicaid)
Section 2.2: Medicare Health Plans
Section 2.3: Commercial or Private Payer in a CMS Multi-Payer Model
Section 3: Supporting Documentation
Section 4: Certification Statement
Payers will complete all four sections, but will only complete the subsection in Section 2 that applies to their payer type. For example, a Medicaid Managed Care Plan will complete Section 2.1, but not Sections 2.2 or 2.3.
All required supporting documentation must be uploaded as attachments in the Supporting Documentation section of the Form.
SECTION 1: Payer Identifying Information
Medicare Health Plans will complete this Form through the Health Plan Management System (HPMS). When available, Payer Identifying Information will pre-populate for payers that already have HPMS accounts.
Payer Type
Select one of the following: [DROP DOWN LIST]
State Medicaid Program
Medicare Health Plan (including Local Coordinated Care Plans, Regional Coordinated Care Plans, Medicare Private Fee-for-Service Plans, Medicare Medical Savings Account Plans, Medicare-Medicaid Plans, 1876 and 1833 Cost Plans, and Programs of All Inclusive Care for the Elderly (PACE) plans)
Other Commercial or Private Payer in a CMS Multi-Payer Model
Payer Contact Information
Non-Medicaid:
Legal Entity Name: _______________
DBA Name (if applicable): __________________
Parent Company or Organization (if applicable): ________________
Medicaid:
State Medicaid Agency Name: ___________
State Medicaid Director Name: _______________
All Payers:
Telephone Number: ____ Fax Number: ____________
Address Line 1 (Street Name and Number): ______
Address Line 2 (Suite, Room, etc.): ___________
City/Town: ______ State: _____ Zip Code +4: ____________
E-mail Address: _______________
Contact Person
If questions arise during the processing of this request, CMS or its contractor will contact the individual shown below.
Is the contact person the State Medicaid Director? [Y/N]
If yes, skip to Section 2.
Contact Information:
First Name: ____ Middle Initial: ____ Last Name: ______
Telephone Number: ____ Fax Number: ____________
Address Line 1 (Street Name and Number): ______
Address Line 2 (Suite, Room, etc.): ___________
City/Town: ______ State: _____ Zip Code +4: ____________
E-mail Address: _______________
SECTION 2: Payment Arrangement Information
SECTION 2.1: Title XIX (Medicaid)
This section includes payment arrangements that the State uses in Medicaid Fee-For-Service, payment arrangements the State requires Medicaid managed care plans to effectuate, and payment arrangements that Medicaid managed care plans and providers voluntarily enter without State involvement.
General Information
Payment Arrangement Name (e.g. [State Name] ACO Model), or terminology used to refer to the payment arrangement: [TEXT BOX]
Describe the participant eligibility criteria for this payment arrangement. [TEXT BOX]
Is this payment arrangement open to all provider types or limited to certain specialties? [SELECT ONE]
If the payment arrangement is limited to certain specialties, select the provider specialties that may participate in the payment arrangement. [DROP-DOWN]
Select the All-Payer QP Performance Period for which this payment arrangement determination is being requested. : [YEAR DROP-DOWN]
Payment arrangement documentation is required to support the answers provided above. Please note the attached document(s) and page number(s) that contain this information. [TEXT BOX]
Availability of Payment Arrangement
Locations where this Payment Arrangement will be available:
States [DROP DOWN LIST]
Counties, if not statewide [DROP DOWN LIST]
Is this payment arrangement available through Medicaid Fee-For-Service? [Y/N]
Is this payment arrangement available through a Medicaid managed care plan? [Y/N]
Payment Arrangement Documentation
Please attach documentation that supports responses to the questions asked in Sections D (CMS Medicaid Medical Home Model Determination) and E (Information for Other Payer Advanced APM Determination) of this Form. Supporting documents may include contracts or excerpts of contracts between Medicaid managed care plans and providers, contracts or excerpts of contracts between Medicaid managed care plans and the State, contracts or excerpts of contracts between the State Medicaid agency and providers, or alternative comparable documentation that supports responses to the questions asked in Sections D and E below.
Upload all documents to the Supporting Documentation section of this Form, and label each document for reference throughout the Form.
CMS will use existing Medicaid documentation in the Payer Initiated Other Payer Advanced APM Determination Process as applicable.
Is information about this payment arrangement included in a State Plan Amendment (SPA), Section 1115 demonstration waiver application, Special Terms and Conditions document, implementation protocol document, or other document describing the 1115 demonstration arrangement approved by CMS? [Y/N]
If yes, please attach the relevant documentation. Note the document name and page number(s) that contain information regarding this payment arrangement [TEXT BOX]
If the information needed to answer the questions in Sections D and E of this Form is not available in the aforementioned Medicaid documentation, note the attached supporting documentation and page numbers that contain this information [TEXT BOX].
Information for CMS Medicaid Medical Home Model Determination
Does the payer request that CMS make a determination regarding whether this payment arrangement is a Medicaid Medical Home Model as defined in 42 CFR 414.1305? [Y/N]
If no, skip to section E.
If yes, list the attached document(s) and page numbers that contain the information required in this section. [TEXT BOX]
For which eligible clinicians with a primary care focus does the payment arrangement include specific design elements? Select all Physician Specialty Codes that apply: 01 General Practice; 08 Family Medicine; 11 Internal Medicine; 16 Obstetrics and Gynecology; 37 Pediatric Medicine; 38 Geriatric Medicine; 50 Nurse Practitioner; 89 Clinical Nurse Specialist; and 97 Physician Assistant. [CHECK BOX]
Does the payment arrangement require empanelment (assigning individual patients to individual providers) of each patient to a primary clinician? [Y/N]
Select all elements from the following list that are required by the payment arrangement, and cite the supporting document(s) and page number(s) that contain this information regarding each requirement. Briefly explain how each criterion is satisfied in the payment arrangement.
Planned coordination of chronic and preventive care. [Y/N] If yes, [TEXT BOX]
Patient access and continuity of care. [Y/N] If yes, [TEXT BOX]
Risk-stratified care management. [Y/N] If yes, [TEXT BOX]
Coordination of care across the medical neighborhood. [Y/N] If yes, [TEXT BOX]
Patient and caregiver engagement. [Y/N] If yes, [TEXT BOX]
Shared decision-making. [Y/N] If yes, [TEXT BOX]
Payment arrangements in addition to, or substituting for, fee-for-service payments (e.g. shared savings or population-based payments). [Y/N] If yes, [TEXT BOX]
Medicaid Medical Home Model Financial Risk Standard
List the attached document(s) and page numbers that contain the information required in this section. [TEXT BOX]
Does the payment arrangement require the participating APM Entity to bear financial risk if actual aggregate expenditures exceed expected aggregate expenditures (i.e. benchmark amount)? [Y/N]
If yes, which of the following actions does the payer take in cases where actual aggregate expenditures exceed expected aggregate expenditures? [CHECK BOX]
Payer withholds payment of services to the APM Entity and/or the APM Entity’s eligible clinicians.
Payer reduces payment rates to APM Entity and/or the APM Entity’s eligible clinicians.
Payer requires direct payments by the APM Entity to the payer.
Payer requires the APM Entity to lose the right to all or part of an otherwise guaranteed payment or payments.
Please describe the action(s) checked above that are taken by the payer in cases where actual aggregate expenditures exceed expected aggregate expenditures. [TEXT BOX]
Medicaid Medical Home Model Nominal Amount Standard
List the attached document(s) and page numbers that contain the information required in this section. [TEXT BOX]
Is the total amount an APM Entity potentially owes or foregoes under the payment arrangement at least 3 percent of the APM Entity’s total revenue under the payer. [Y/N]
If yes, please describe how the amount that an APM entity owes or foregoes is calculated. [TEXT BOX]
Information for Other Payer Advanced APM Determination
Certified Electronic Health Record Technology (CEHRT)
List the attached document(s) and page numbers that contain the information required in this section. [TEXT BOX]
Does the payment arrangement require at least 50 percent of participating eligible clinicians in each APM Entity (or each hospital if hospitals are the APM participants) to use CEHRT as defined in 42 CFR 414.1305 to document and communicate clinical care, as required by 42 CFR 414.1420(b)? [Y/N]
For purposes of this Form, the APM Entity is the practitioner or group of practitioners that participates in the payment arrangement.
Quality Measure Use
List the attached document(s) and page numbers that contain the information required in this section. [TEXT BOX]
Does the payment arrangement apply any quality measures that are comparable to MIPS quality measures as required by 42 CFR 414.1420(c)? [Y/N]
If yes, does at least one quality measure have an evidence-based focus, is it reliable and valid, and does it meet at least one of the following criteria: [Y/N]
Any of the quality measures included on the proposed annual list of MIPS quality measures;
Quality measures that are endorsed by a consensus-based entity;
Quality measures developed under section 1848(s) of the Act;
Quality measures submitted in response to the MIPS Call for Quality Measures under section 1848(q)(2)(D)(ii) of the Act or
Any other quality measures that CMS determines to have an evidence-based focus and are reliable and valid.
A minimum of one quality measure that meets the above criteria and is an outcome measure is required in order to satisfy the Quality Measure Use criterion. Please provide the following information for each quality measure included in the payment arrangement that you wish for CMS to consider for purposes of satisfying this criterion. [TEXT BOX FOR EACH MEASURE]
Measure title
MIPS measure identification number (if applicable)
National Quality Forum (NQF) number (if applicable)
If the measure is neither a MIPS measure nor a currently endorsed NQF measure, cite the scientific evidence and/or clinical practice guidelines that support the use of the measure.
Is the measure an outcome measure?
Describe how the measure has an evidence-based focus, is reliable and valid, by meeting one the following criteria:
Any of the quality measures included on the proposed annual list of MIPS quality measures;
Quality measures that are endorsed by a consensus-based entity;
Quality measures developed under section 1848(s) of the Act;
Quality measures submitted in response to the MIPS Call for Quality Measures under section 1848(q)(2)(D)(ii) of the Act or
Any other quality measures that CMS determines to have an evidence-based focus and are reliable and valid
Are any of the above measures outcome measures? [Y/N]
If no, check here if no outcomes measures that are relevant to this payment arrangement are available on the MIPS quality measure list. [CHECK BOX]
Generally Applicable Financial Risk Standard
Section not applicable for Medicaid Medical Home Models
List the attached document(s) and page numbers that contain the information required in this section. [TEXT BOX]
Does the payment arrangement require the participating APM Entity to bear financial risk if actual aggregate expenditures exceed expected aggregate expenditures (i.e. benchmark amount)? [Y/N]
If yes, which of the following actions does the payer take in cases where actual aggregate expenditures exceed expected aggregate expenditures? [CHECK BOX]
Payer withholds payment of services to the APM Entity and/or the APM Entity’s eligible clinicians.
Payer reduces payment rates to APM Entity and/or the APM Entity’s eligible clinicians.
Payer requires direct payments by the APM Entity to the payer.
Please describe the action(s) checked above that are taken by the payer in cases where actual aggregate expenditures exceed expected aggregate expenditures. [TEXT BOX]
Is this payment arrangement a capitation arrangement? [Y/N]
A capitation arrangement for purposes of Other Payer Advanced APM determinations is a payment arrangement in which a per capita or otherwise predetermined payment is made under the payment arrangement for all items and services for which payment is made through the payment arrangement furnished to a population of beneficiaries, and no settlement is performed for reconciling or sharing losses incurred or savings earned.
If yes, describe how this payment arrangement is a capitation arrangement. [TEXT BOX]
Generally Applicable Nominal Amount Standard
Section not applicable for Medicaid Medical Home Models.
List the attached document(s) and page numbers that contain the information required in this section. [TEXT BOX]
Please briefly describe the payment arrangement’s risk methodology. Note the risk rate(s), expenditures that are included in risk calculations, circumstances under which an APM Entity is required to repay or forego payment, and any other key components of the risk methodology. [TEXT BOX]
Is the marginal risk an APM Entity potentially owes or foregoes under the payment arrangement at least 30 percent? [Y/N]
If yes, please describe the marginal risk rate(s) and the actions required (e.g., repayment or forfeit of future payment) under the payment arrangement. [TEXT BOX]
Is the minimum loss rate with which an APM Entity operates under the payment arrangement no more than 4 percent? [Y/N]
If yes, please describe the minimum loss rate. [TEXT BOX]
Is the total amount an APM Entity potentially owes or foregoes under the payment arrangement at least:
8 percent of the total revenue from the payer of providers and suppliers participating in each APM Entity in the payment arrangement if financial risk is expressly defined in terms of revenue [Y/N]
If yes, please explain how risk is expressly defined in terms of revenue. [TEXT BOX]
3 percent of the expected expenditures for which an APM Entity is responsible under the payment arrangement? [CHECK BOX]
If yes, please describe how the amount that an APM Entity owes or foregoes is calculated. [TEXT BOX]
SECTION 2.2: Medicare Health Plans
This section is applicable for Medicare Health Plans, including: Medicare Advantage, Medicare-Medicaid Plans, 1876 and 1833 Cost Plans, and Programs of All Inclusive Care for the Elderly (PACE) plans.
General Information
CMS will collect this information through HPMS.
Please select the type of Medicare Health Plan that includes this payment arrangement. [DROP-DOWN]
Payment Arrangement Name (e.g. [Payer Name] Oncology Care Model), or terminology used to refer to the payment arrangement: [TEXT BOX]
Describe the participant eligibility criteria for this payment arrangement. [TEXT BOX]
Is this payment arrangement open to all provider types or limited to certain specialties? [SELECT ONE]
If the payment arrangement is limited to certain specialties, select the provider specialties that may participate in the payment arrangement. [DROP-DOWN]
Select the All-Payer QP Performance Period for which this payment arrangement determination is being requested. [YEAR DROP-DOWN]
Payment arrangement documentation is required to support the answers provided above. Please note the attached document(s) and page number(s) that contain this information. [TEXT BOX]
Availability of Payment Arrangement
CMS will collect contract service area information through HPMS.
Through which plans and in what locations is this payment arrangement offered? [SELECT OR ENTER PLAN NAMES AND LOCATIONS]
Payment Arrangement Documentation
Please attach documentation that supports responses to the questions asked in Section D (Information for Other Payer Advanced APM Determination) of this Form. Supporting documents may include contracts or excerpts of contracts between the payer and providers, or alternative comparable documentation that supports responses to the questions asked in Section D below.
Upload all documents to the Supporting Documentation section of this Form, and label each document for reference throughout the Form.
Information for Other Payer Advanced APM Determination
Certified Electronic Health Record Technology (CEHRT)
List the attached document(s) and page numbers that contain the information required in this section. [TEXT BOX]
Does the payment arrangement require at least 50 percent of participating eligible clinicians in each APM Entity (or each hospital if hospitals are the APM participants) to use CEHRT as defined in 42 CFR 414.1305 to document and communicate clinical care, as required by 42 CFR 414.1420(b)? [Y/N]
For purposes of this Form, the APM Entity is the practitioner or group of practitioners that participates in the payment arrangement.
Quality Measure Use
List the attached document(s) and page numbers that contain the information required in this section. [TEXT BOX]
Does the payment arrangement apply any quality measures that are comparable to MIPS quality measures as required by 42 CFR 414.1420(c)? [Y/N]
If yes, does at least one quality measure have an evidence-based focus, is it reliable and valid, and does it meet at least one of the following criteria: [Y/N]
Any of the quality measures included on the proposed annual list of MIPS quality measures;
Quality measures that are endorsed by a consensus-based entity;
Quality measures developed under section 1848(s) of the Act;
Quality measures submitted in response to the MIPS Call for Quality Measures under section 1848(q)(2)(D)(ii) of the Act or
Any other quality measures that CMS determines to have an evidence-based focus and are reliable and valid.
A minimum of one quality measure that meets the above criteria and is an outcome measure is required in order to satisfy the Quality Measure Use criterion. Please provide the following information for each quality measure included in the payment arrangement that you wish for CMS to consider for purposes of satisfying this criterion. [TEXT BOX FOR EACH MEASURE]
Measure title
MIPS measure identification number (if applicable)
National Quality Forum (NQF) number (if applicable)
If the measure is neither a MIPS measure nor a currently endorsed NQF measure, cite the scientific evidence and/or clinical practice guidelines that support the use of the measure.
Is the measure an outcome measure?
Describe how the measure has an evidence-based focus, is reliable and valid, by meeting one the following criteria:
Any of the quality measures included on the proposed annual list of MIPS quality measures;
Quality measures that are endorsed by a consensus-based entity;
Quality measures developed under section 1848(s) of the Act;
Quality measures submitted in response to the MIPS Call for Quality Measures under section 1848(q)(2)(D)(ii) of the Act or
Any other quality measures that CMS determines to have an evidence-based focus and are reliable and valid
Are any of the above measures outcome measures? [Y/N]
If no, check here if no outcomes measures that are relevant to this payment arrangement are available on the MIPS quality measure list. [CHECK BOX]
Generally Applicable Financial Risk Standard
List the attached document(s) and page numbers that contain the information required in this section. [TEXT BOX]
Does the payment arrangement require the participating APM Entity to bear financial risk if actual aggregate expenditures exceed expected aggregate expenditures (i.e. benchmark amount)? [Y/N]
If yes, which of the following actions does the payer take in cases where actual aggregate expenditures exceed expected aggregate expenditures? [CHECK BOX]
Payer withholds payment of services to the APM Entity and/or the APM Entity’s eligible clinicians.
Payer reduces payment rates to APM Entity and/or the APM Entity’s eligible clinicians.
Payer requires direct payments by the APM Entity to the payer.
Please describe the action(s) checked above that are taken by the payer in cases where actual aggregate expenditures exceed expected aggregate expenditures. [TEXT BOX]
Is this payment arrangement a capitation arrangement? [Y/N]
A capitation arrangement for purposes of Other Payer Advanced APM determinations is a payment arrangement in which a per capita or otherwise predetermined payment is made under the payment arrangement for all items and services for which payment is made through the payment arrangement furnished to a population of beneficiaries, and no settlement is performed for reconciling or sharing losses incurred or savings earned.
If yes, describe how this payment arrangement is a capitation arrangement. [TEXT BOX]
Generally Applicable Nominal Amount Standard
List the attached document(s) and page numbers that contain the information required in this section. [TEXT BOX]
Please briefly describe the payment arrangement’s risk methodology. Note the risk rate(s), expenditures that are included in risk calculations, circumstances under which an APM Entity is required to repay or forego payment, and any other key components of the risk methodology. [TEXT BOX]
Is the marginal risk an APM Entity potentially owes or foregoes under the payment arrangement at least 30 percent? [Y/N]
If yes, please describe the marginal risk rate(s) and the actions required (e.g., repayment or forfeit of future payment) under the payment arrangement. [TEXT BOX]
Is the minimum loss rate with which an APM Entity operates under the payment arrangement no more than 4 percent? [Y/N]
If yes, please describe the minimum loss rate. [TEXT BOX]
Is the total amount an APM Entity potentially owes or foregoes under the payment arrangement at least:
8 percent of the total revenue from the payer of providers and suppliers participating in each APM Entity in the payment arrangement if financial risk is expressly defined in terms of revenue [Y/N]
If yes, please explain how risk is expressly defined in terms of revenue. [TEXT BOX]
3 percent of the expected expenditures for which an APM Entity is responsible under the payment arrangement? [CHECK BOX]
If yes, please describe how the amount that an APM Entity owes or foregoes is calculated. [TEXT BOX]
SECTION 2.3: Commercial or Private Payer in a CMS Multi-Payer Model
General Information
Select the CMS Multi-Payer Model: [DROP DOWN LIST]
Payment Arrangement Name (e.g. [Payer Name] Oncology Care Model), or terminology used to refer to the payment arrangement: [TEXT BOX]
Describe the participant eligibility criteria for this payment arrangement. [TEXT BOX]
Is this payment arrangement open to all provider types or limited to certain specialties? [SELECT ONE]
If the payment arrangement is limited to certain specialties, select the provider specialties that may participate in the payment arrangement. [DROP-DOWN]
Select the All-Payer QP Performance Period for which this payment arrangement determination is being requested. : [YEAR DROP-DOWN]
Payment arrangement documentation is required to support the answers provided above. Please note the attached document(s) and page number(s) that contain this information. [TEXT BOX]
Availability of Payment Arrangement
Select locations where this payment arrangement will be available:
Nationwide [Y/N]
States [DROP DOWN LIST]
Payment Arrangement Documentation
Please attach documentation that supports responses to the questions asked in Section D (Information for Other Payer Advanced APM Determination) of this Form. Supporting documents may include contracts or excerpts of contracts between the payer and providers, or alternative comparable documentation that supports responses to the questions asked in Section D below.
Upload all documents to the Supporting Documentation section of this Form, and label each document for reference throughout the Form.
Note that CMS will access the payer’s CMS Memorandum of Understanding or other relevant documentation for participation in the CMS Multi-Payer Model.
Information for Other Payer Advanced APM Determination
Certified Electronic Health Record Technology (CEHRT)
List the attached document(s) and page numbers that contain the information required in this section. [TEXT BOX]
Does the payment arrangement require at least 50 percent of participating eligible clinicians in each APM Entity (or each hospital if hospitals are the APM participants) to use CEHRT as defined in 42 CFR 414.1305 to document and communicate clinical care, as required by 42 CFR 414.1420(b)? [Y/N]
For purposes of this Form, the APM Entity is the practitioner or group of practitioners that participates in the payment arrangement.
Quality Measure Use
List the attached document(s) and page numbers that contain the information required in this section. [TEXT BOX]
Does the payment arrangement apply any quality measures that are comparable to MIPS quality measures as required by 42 CFR 414.1420(c)? [Y/N]
If yes, does at least one quality measure have an evidence-based focus, is it reliable and valid, and does it meet at least one of the following criteria: [Y/N]
Any of the quality measures included on the proposed annual list of MIPS quality measures;
Quality measures that are endorsed by a consensus-based entity;
Quality measures developed under section 1848(s) of the Act;
Quality measures submitted in response to the MIPS Call for Quality Measures under section 1848(q)(2)(D)(ii) of the Act or
Any other quality measures that CMS determines to have an evidence-based focus and are reliable and valid.
A minimum of one quality measure that meets the above criteria and is an outcome measure is required in order to satisfy the Quality Measure Use criterion. Please provide the following information for each quality measure included in the payment arrangement that you wish for CMS to consider for purposes of satisfying this criterion. [TEXT BOX FOR EACH MEASURE]
Measure title
MIPS measure identification number (if applicable)
National Quality Forum (NQF) number (if applicable)
If the measure is neither a MIPS measure nor a currently endorsed NQF measure, cite the scientific evidence and/or clinical practice guidelines that support the use of the measure.
Is the measure an outcome measure?
Describe how the measure has an evidence-based focus, is reliable and valid, by meeting one the following criteria:
Any of the quality measures included on the proposed annual list of MIPS quality measures;
Quality measures that are endorsed by a consensus-based entity;
Quality measures developed under section 1848(s) of the Act;
Quality measures submitted in response to the MIPS Call for Quality Measures under section 1848(q)(2)(D)(ii) of the Act or
Any other quality measures that CMS determines to have an evidence-based focus and are reliable and valid
Are any of the above measures outcome measures? [Y/N]
If no, check here if no outcomes measures that are relevant to this payment arrangement are available on the MIPS quality measure list. [CHECK BOX]
Generally Applicable Financial Risk Standard
List the attached document(s) and page numbers that contain the information required in this section. [TEXT BOX]
Does the payment arrangement require the participating APM Entity to bear financial risk if actual aggregate expenditures exceed expected aggregate expenditures (i.e. benchmark amount)? [Y/N]
If yes, which of the following actions does the payer take in cases where actual aggregate expenditures exceed expected aggregate expenditures? [CHECK BOX]
Payer withholds payment of services to the APM Entity and/or the APM Entity’s eligible clinicians.
Payer reduces payment rates to APM Entity and/or the APM Entity’s eligible clinicians.
Payer requires direct payments by the APM Entity to the payer.
Please describe the action(s) checked above that are taken by the payer in cases where actual aggregate expenditures exceed expected aggregate expenditures. [TEXT BOX]
Is this payment arrangement a capitation arrangement? [Y/N]
A capitation arrangement for purposes of Other Payer Advanced APM determinations is a payment arrangement in which a per capita or otherwise predetermined payment is made under the payment arrangement for all items and services for which payment is made through the payment arrangement furnished to a population of beneficiaries, and no settlement is performed for reconciling or sharing losses incurred or savings earned.
If yes, describe how this payment arrangement is a capitation arrangement. [TEXT BOX]
Generally Applicable Nominal Amount Standard
List the attached document(s) and page numbers that contain the information required in this section. [TEXT BOX]
Please briefly describe the payment arrangement’s risk methodology. Note the risk rate(s), expenditures that are included in risk calculations, circumstances under which an APM Entity is required to repay or forego payment, and any other key components of the risk methodology. [TEXT BOX]
Is the marginal risk an APM Entity potentially owes or foregoes under the payment arrangement at least 30 percent? [Y/N]
If yes, please describe the marginal risk rate(s) and the actions required (e.g., repayment or forfeit of future payment) under the payment arrangement. [TEXT BOX]
Is the minimum loss rate with which an APM Entity operates under the payment arrangement no more than 4 percent? [Y/N]
If yes, please describe the minimum loss rate. [TEXT BOX]
Is the total amount an APM Entity potentially owes or foregoes under the payment arrangement at least:
8 percent of the total revenue from the payer of providers and suppliers participating in each APM Entity in the payment arrangement if financial risk is expressly defined in terms of revenue [Y/N]
If yes, please explain how risk is expressly defined in terms of revenue. [TEXT BOX]
3 percent of the expected expenditures for which an APM Entity is responsible under the payment arrangement? [CHECK BOX]
If yes, please describe how the amount that an APM Entity owes or foregoes is calculated. [TEXT BOX]
SECTION 3: Supporting Documentation
Please upload all supporting documentation here. Documents should be labeled for reference use throughout the Form.
SECTION 4: Certification Statement
I have read the contents of this submission. By submitting this Form, I certify that I am legally authorized to bind the payer. I further certify that the information contained herein is true, accurate, and complete, and I authorize the Centers for Medicare & Medicaid Services (CMS) to verify this information. If I become aware that any information in this Form is not true, accurate, or complete, I will notify CMS of this fact immediately. I understand that the knowing omission, misrepresentation, or falsification of any information contained in this document or in any communication supplying information to CMS may be punished by criminal, civil, or administrative penalties, including fines, civil damages and/or imprisonment.
[DATE, AUTHORIZED INDIVIDUAL NAME, TITLE, PAYER NAME]
Payer Initiated Submission Form Privacy Act Statement
The Centers for Medicare & Medicaid Services (CMS) is authorized to collect the information requested on this Form by sections 1833(z)(2)(B)(ii) and (z)(2)(C)(ii) of the Social Security Act (42 U.S.C. 1395l).
The purpose of collecting this information is to determine whether the submitted payment arrangement is an Other Payer Advanced APM as set forth in 42 C.F.R. 414.1420 for the relevant All-Payer QP Performance Period.
The information in this request will be disclosed according to the routine uses described below. Information from these systems may be disclosed under specific circumstances to:
CMS contractors to carry out Medicare functions, collating or analyzing data, or to detect fraud and abuse;
A congressional office in response to a subpoena;
To the Department of Justice or an adjudicative body when the agency, an agency employee, or the United States Government is party to litigation and the use of the information is compatible with the purpose for which the agency collected the information;
To the Department of Justice for investigating and prosecuting violations of the Social Security Act, to which criminal penalties are attached.
Protection of Proprietary Information
Privileged or confidential commercial or financial information collected in this Form is protected from public disclosure by Federal law 5 U.S.C. 552(b)(4) and Executive Order 12600.
Protection of Confidential Commercial and/or Sensitive Personal Information
If any information within this request (or attachments thereto) constitutes a trade secret or privileged or confidential information (as such terms are interpreted under the Freedom of Information Act and applicable case law), or is of a highly sensitive personal nature such that disclosure would constitute a clearly unwarranted invasion of the personal privacy of one or more persons, then such information will be protected from release by CMS under 5 U.S.C. 552(b)(4) and/or (b)(6), respectively.
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 0938-1314 (Expiration date: XX/XX/XXXX). The time required to complete this information collection is estimated to average [Insert Time (hours or minutes)] 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. ****CMS Disclosure**** 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 [Benjamin Chin 410-786-0679].
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Elizabeth Lamoste |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |