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May 24, 2017

Determining MIPS Eligibility with the CMS Look-up Tool

Clinicians have been waiting to find out if they are eligible for the new Merit-Based Incentive Payment System (MIPS), and after continued delays, CMS is providing answers. CMS recently mailed letters to Medicare participants based on Tax Identification Number (TIN). The letter will identify clinicians based on their National Provider Identifier (NPI) linked to the TIN and if the clinician individually or the group TIN is exempt or included in MIPS. Letters are mailed to the TIN address on file with Medicare.

If You Have Not Received a Letter

For those who have not received a letter, a look-up tool is available from CMS, searching by individual provider’s NPI.  The look-up tool, similar to the letter, will note if Medicare has an individual linked to more than one organization TIN and the reporting requirement under each provider’s unique NPI/TIN combination. The look-up tool can be especially helpful to practice administrators or clinicians who did not personally view the letter mailed because it was received by administrative leaders or a corporate office.

Determining Eligibility

Keep in mind eligibility determination is based on a first review of Medicare’s claims records from its fiscal year closed August 31, 2016.  Below are reasons why a clinician may be deemed exempt from the 2017 transition year for MIPS:

  • First year for Medicare enrollment
  • Meeting the low-volume threshold
  • Qualified Participant in an Advanced APM

Clinicians with a notice of exemption from MIPS in 2017 will be exempt based on Medicare’s initial determination. A second review of claims data will occur for dates September 1, 2016 through August 31, 2017. Clinicians included in MIPS by the first determination period may be exempt in December 2017 if exclusions were met upon the second claims review.

Acronym legend
APM: Alternative Payment Model

CMS: Centers for Medicare and Medicaid Services
QPP: Quality Payment Program
MACRA: Medicare Access and CHIP Reauthorization Act of 2015
MIPS: Merit-based Incentive Payment System
NPI: National Provider Identifier
TIN: Tax Identification Number

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