CROSSWALK Appendix B: 2026 Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determina

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

All-Payer Payer Initiated 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 1, Line 18
Reason for Change:
Alignment with current year.
CY 2024 Final Rule text:
2025 for the 2026
CY 2025 Final Rule text:
2026 for the 2027
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Change #2:
Location: Page 1, Line 24
Reason for Change:
Alignment with current year.
CY 2024 Final Rule text:
2025 for the 2026
CY 2025 Final Rule text:
2026 for the 2027
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Change #3:
Location: Page 1, Line 29
Reason for Change:
Alignment with current year.
CY 2024 Final Rule text:
2025 for the 2026
CY 2025 Final Rule text:
2026 for the 2027

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 request that CMS determine whether such
payment arrangements are Other Payer Advanced Alternative Payment Models (APMs) under the Quality Payment Program as
set forth in 42 CFR 414.1420. The time required to complete this information collection is estimated to average 10 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 mandate 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.