Skip to Main Content

Self-Nomination/Registration

Self-Nomination/Registration through the PV-PQRS Registration System

The Physician Value-Physician Quality Reporting System (PV-PQRS) Registration System will allow authorized representatives of a group practice to perform the following tasks on behalf of the group practice from April 1, 2014 to September 30, 2014:

  1. Register to participate in the PQRS Group Practice Reporting Option (GPRO) in 2014 via:
    • Qualified PQRS Registry;
    • Electronic Health Record (EHR) [via Direct EHR using Certified EHR Technology (CEHRT) or CEHRT via Data Submission Vendor]; or
    • Web Interface (for groups with 25 or more eligible professionals (EPs) only).
  2. If a group practice has 25 or more EPs, then the group can elect to supplement its PQRS reporting mechanism with the Clinician and Group Consumer Assessment of Health Providers and Systems (CG-CAHPS) survey. However, if the group practice has 100 or more EPs and has selected the Web Interface reporting mechanism for 2014, then the group is required to report the CAHPS survey, and the group can elect to include its performance on the 2014 CAHPS survey in the calculation of the group’s 2016 Value-Based Payment Modifier (Value Modifier). Note:
    • For all group practices that have elected or are required to report the CAHPS survey, please note that for 2014, CMS has already contracted with a certified survey vendor to implement these surveys on behalf of the group.
    • Please note that some group practices may have insufficient sample sizes as a result of patient attribution and sampling rules to have valid and reliable CAHPS results; therefore, groups should make sure to report sufficient number of measures to meet program requirements.
  3. View a summary of the group practice’s Program Year (PY) 2013 Registration information (if available).

The Registration System can be accessed at https://portal.cms.gov/ using a valid Individuals Authorized Access to the CMS Computer Services (IACS) User ID and Password.

A “group practice” is defined as a single Medicare billing Taxpayer Identification Number (TIN) with 2 or more individual EPs (as identified by their individual National Provider Identifier (NPI)) who have reassigned their billing rights to the TIN.

Individual EPs: Individual EPs that choose to participate in the PQRS as an individual in 2014 do not need to register in the Registration System. Individual EPs may participate in the PQRS as an individual in 2014 via claims, CMS-qualified registry, qualified clinical data registry, or EHR. Alternatively, if the individual EP is part of a group practice that has 2 or more EPs and the group chooses to participate in the PQRS as a group in 2014, then the group must register in the Registration System between April 1, 2014 and September 30, 2014.

Group Practices that Have to Register in the Registration System in 2014

Group practices of all sizes (with 2 or more EPs) that choose to participate in the PQRS as a group, including those who have EPs also participating in a Pioneer ACO or the Comprehensive Primary Care (CPC)* Initiative. Specifically,

  • Group practices with 2 or more EPs that want to report via the Qualified Registry reporting mechanism.
  • Group practices with 2 or more EPs that want to report via Direct EHR using CEHRT or CEHRT via Data Submission Vendor.
  • Group practices with 25 or more EPs that want to select the Web Interface reporting mechanism.
  • Group practices with 25 or more EPs that want to supplement their PQRS reporting mechanism with the CAHPS survey, or group practices with 100 or more EPs that selected the Web Interface reporting mechanism and want to include their performance on the required 2014 CAHPS survey in the calculation of the group’s 2016 Value Modifier.
  • Group practices with 10 or more EPs that want to avoid the -2% automatic Value Modifier payment adjustment in 2016 by reporting PQRS quality data at the group level.
    Note: These groups must also meet the criteria to avoid the 2016 PQRS payment adjustment in order to avoid the -2% automatic Value Modifier payment adjustment in 2016.

* The CPC EPs who elect to report to PQRS as a group will not be eligible to elect the CPC PQRS waiver.

For additional information about the PQRS program, CAHPS surveys, Group Practice Reporting Options, and Value Modifier policies, please refer to the links in the “Resources” section. Instructions for how group practices can register in the Registration System are available in the “Downloads” section.

Group Practices that Do Not Have to Register

  • Group practices that participate in the Medicare Shared Savings Program.
  • Group practices that only provide care to Medicare beneficiaries who are enrolled in a Medicare Advantage plan.
  • Group practices that only practice in a Rural Health Clinic.
  • Group practices that only practice in a Federally Qualified Health Center.
  • Group practices with individual EPs that choose to participate in the PQRS as an individual via claims, CMS-qualified registry, qualified clinical data registry, or EHR.

IACS Account Required

An IACS account with a PV-PQRS System role is required to access the Registration System. Users are limited to 1 account per person, but an account can be associated with multiple group practices (as identified by the TIN) or individual EPs (as identified by the TIN/NPI).

If you have an existing IACS account, but not one with a PV-PQRS System role, then you must:

  • Ensure your account is still active by contacting the QualityNet Help Desk, and
  • Add a group practice PV-PQRS System role to your account.

You can sign up for a new IACS account or modify an existing account on the IACS website at https://applications.cms.hhs.gov/. If you already have an IACS account with a PV-PQRS System role, but you forgot your User ID and/or password, then you can retrieve the User ID and reset the password on the IACS website.

Instructions for requesting each PV-PQRS System role for new or existing IACS account users are available in the “Downloads” section.

IACS Roles for Group Practices

Group practices are identified in IACS by their Medicare billing TIN. One authorized representative of a group practice must sign up for an IACS account with the “PV-PQRS Group Security Official” role and register the group practice as an Organization in IACS. This person is the Group’s primary Security Official. There can be only one primary Group Security Official, but one or more backup Group Security Officials.

Primary or backup Group Security Official role allows the user to perform the following tasks on behalf of the group practice:

  1. Access the Registration System in order to perform the functions described above (e.g., select or change the group practice’s PQRS group reporting mechanism for 2014).
  2. If available, view the group practice’s Quality and Resource Use Report and 2012 Episodes Report (after May 2014).
  3. Approve requests for the “PV-PQRS Group Representative” role in IACS.

“PV-PQRS Group Representative” roles can be requested after the group practice has an approved primary Group Security Official in IACS. This role allows the user to perform tasks 1 and 2 as listed above.

Resources

For assistance with the IACS sign up process, IACS role selection, or registering in the Registration System, please contact the QualityNet Help Desk:

  • Monday – Friday: 8:00 am – 8:00 pm EST
  • Phone: (866) 288-8912 (TTY 1-877-715-6222)
  • Fax: (888) 329-7377
  • Email: qnetsupport@hcqis.org

PQRS Program

Group Practice Reporting Option

Value Modifier and Quality Tiering