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MIPS Eligibility Notification

CMS is issuing Merit-Based Incentive Payment System (MIPS) eligibility notifications in late April through May. These notifications include details regarding whether an individual clinician (National Provider Identifier) or group (Tax Identification Number) meets the MIPS low-volume threshold exemption for billing $30,000 or less in Medicare allowed charges or seeing 100 or fewer Medicare beneficiaries. This eligibility was determined based on Medicare Part B claims data from September 1, 2015 through August 31, 2016. According to CMS, these notifications will be issued by the Medicare Administrative Contractor (MAC) to TINs.

Please note CMS officials have informed NAACOS staff that Track 1 ACOs will not be receiving these notifications. According to CMS staff, Track 1 ACO TINs as well as the individual NPIs in their respective TINs will not be included in this eligibility notification process. A sample notification is available here. The notification will include two attachments. Attachment A includes a list of the clinician(s) associated with the TIN, the TIN’s National Provider Identifier(s) (NPIs), and whether they are subject to MIPS. Attachment B contains Frequently Asked Questions (FAQs), including the following FAQs related to ACOs: 

  • I participate in the Medicare Shared Savings Program (SSP) Track 1. What do I do?

If your TIN is in a Track 1 SSP ACO you are subject to MIPS under MIPS special APM rules, including if your TIN bills $30,000 or less. You should continue to work with your ACO to meet your APM requirements. You can confirm your participation by visiting where you can also learn about special scoring benefits. 

  • How do I know if I’m in an Advanced APM and therefore possibly exempt from MIPS?

CMS will take three “snapshots” throughout the performance year to determine which eligible clinicians are participating in an Advanced APM and whether they meet the payment or patient thresholds to become Qualifying APM Participants (QPs). Reaching the QP threshold at any one of the three QP determinations will result in QP status for the eligible clinicians in the Advanced APM Entity. These snapshots will take place on approximately March 31, June 30, and August 31. CMS will provide notification of QP status before January 1, 2018. 

Qualifying APM Participants will earn an APM incentive payment and be exempt from MIPS reporting requirements and payment adjustments because sufficient participation in an Advanced APM is achieved. You can visit http://go.cms.gov/APMlist to find the latest list of Advanced APMs for 2017. 

  • I’m in an APM, but you’ve informed me that I’m in MIPS. What am I supposed to do?

All eligible clinicians are in MIPS unless we determine at one of the snapshot points during the performance year that participation in an Advanced APM is sufficient (in terms of payments or patient thresholds) to be a Qualifying APM participant (QP), or to be a Partial Qualifying APM participant (and an election is made not to report to MIPS). If you are in an APM that is not an Advanced APM, you may be eligible for special APM scoring under MIPS, which is designed to recognize your APM participation efforts and performance as well as minimize reporting burden. Please make sure you meet APM quality reporting requirements, including, where applicable, working with your ACO that will report quality data for MIPS on your behalf for the quality performance category. You may be required to submit certain information apart from the APM, for example, information for the Advancing Care Information category. You can contact the Quality Payment Program to understand the special benefits you have through your APM that will help you be successful in MIPS. 

  • I’m in an APM, but you’ve informed me that I’m not eligible for MIPS. Should I continue participating in the APM?

Yes! You should continue to fulfill your APM’s requirements. The Quality Payment Program does NOT change how any particular APM operates or rewards value, and APMs have their own quality reporting and participation requirements. Visit your APM’s website to learn more about your requirements.

These notifications do not include information regarding whether TINs and/or NPIs associated with the TIN have met Qualifying APM Professional (QP) thresholds. As a reminder, for the 2019 payment year, the QP performance period runs from January 1 through August 31, 2017. During that QP Performance Period, CMS will make QP determinations at three separate times based on the eligible clinicians who are billing Medicare through MSSP ACO Participant TINs. Should an ACO meet the QP threshold the first time, those clinicians would be considered QPs for the year. CMS will also make the QP determination two additional times, each time based on the eligible clinicians who are part of the MSSP ACO Participant TINs (i.e., those who reassign their Medicare billing rights to an ACO Participant TIN). Therefore, if an ACO meets the QP threshold once, the QP status is achieved for the year but it would only apply to the eligible clinicians who reassign their Medicare billing rights to an MSSP ACO Participant TIN on the specific date when CMS accesses the Medicare enrollment information from the Provider Enrollment, Chain, and Ownership System (PECOS). Those dates are March 31, June 30, and August 31. The process of identifying specific eligible clinicians in a Next Generation ACO is different because ACOs in that model are not required to have full TIN participation as is required under MSSP. Under the Next Generation ACO Model, not all providers within a TIN must participate in the ACO so CMS will identify eligible clinicians in Next Generation ACOs based on the TIN/NPI combinations from the Participant List that is finalized prior to the start of the performance year. New NPIs cannot be added as Next Generation Participants once the performance year begins. In the final Medicare Access and CHIP Reauthorization Act (MACRA) rule, CMS states it will notify Advanced APM Entities and eligible clinicians of their QP or Partial QP status as soon as the agency has made the determination and performed all necessary validation of the results.

NAACOS is obtaining additional details from CMS staff and will continue to update members as more information is provided. For more information regarding how MIPS applies to ACOs, access our member resource, The ACO Guide to MACRA or you can email us at advocacy@naacos.com