CROSSWALK Appendix D: 2026 Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations

OMB Control Number: 0938-1314
Expiration Date: 02/28/2027

All-Payer QP Data Submission Form
CY 2025 Final versus CY 2026 Final

Burden impact: The changes to this form reflect policies in the CY 2025 Physician Fee
Schedule (PFS) Final Rule for the Quality Payment Program. There are no impacts to burden
as a result of these changes.
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Change #1:
Location: Page 6, Line 5
Reason for Change:
Year updated.
CY 2025 Final Rule text:
2025
CY 2026 Final Rule text:
2026
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Change #2
Location: Page 6, Line 28
Reason for Change:
Year updated.
CY 2025 Final Rule text:
January 1, 2025-June 30, 2025
CY 2026 Final Rule text:
January 1, 2026-June 30, 2026
*****
Change #3:
Location: Page 7, Line 26
Reason for Change:
Year updated.
CY 2025 Final Rule text:
January 1, 2025-June 30, 2025
CY 2026 Final Rule text:
January 1, 2026-June 30, 2026
*****
Change #4:
Location: Page 7, Line 42
Reason for Change:
Year updated.
CY 2025 Final Rule text:
January 1, 2025-June 30, 2025
CY 2026 Final Rule text:
January 1, 2026-June 30, 2026

According to the Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.), 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: 2/28/2027). This information collection is the tool to be used to request that CMS
determine whether Eligible Clinicians are QPs under the All-Payer Combination Option of the
Quality Payment Program (QPP) as set forth in 42 CFR 414.1425. The time required to
complete this information collection is estimated to average 5 hours per response, including the
time to review instructions, search existing data resources, gather the data needed, to review
and complete the information collection. This information collection is voluntary and all
information collected will be kept private in accordance with regulations at 45 CFR 155.260,
Privacy and Security of Personally Identifiable Information.  Pursuant to this regulation, CMS
may only use or disclose personally identifiable information to the extent that such information
is necessary to carry out their statutory and regulatory mandated functions. 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, MD 21244-1850. If you have questions or concerns regarding
where to submit your documents, please contact QPP at qpp@cms.hhs.gov.
Under the Privacy Act of 1974 (5 U.S.C. 552a) any personally identifying information obtained
will be kept private to the extent of the law.