2019 CMS MIPS QCDR Attestation and Attestation Template

To meet CMS requirements for QCDR submission, all individuals and groups must complete the Attestation tab in the MIPS Portal. This attestation states that you authorize the ACR NRDR QCDR to submit to CMS on behalf of your TINs and/or NPIs.

The attestation consists of the following:

In consideration of participation in the Merit-based Incentive Payment System (MIPS) administered by the U.S. Department of Health & Human Services Centers for Medicare & Medicaid Services ("CMS"), through the use of the American College of Radiology (ACR) National Radiology Data Registry Qualified Clinical Data Registry (NRDR QCDR), I agree and attest to the following:

1. I understand that CMS may publicly disclose performance data for each performance category associated with the MIPS program. Such public disclosure will not include any patient-specific information.

2. I confirm on behalf of each of the indicated TIN(s) and/or NPI(s) Medicare Part B participation and eligibility for the Merit-based Incentive Payment System (MIPS).

3. I agree to provide documentation to ACR to validate active tax IDs (TINs) for which I am submitting MIPS data before the close of the current MIPS performance period.

4. If ACR determines that a data audit or validation is necessary, I will timely provide any data or supporting documentation requested for such purposes.

5. I attest that the data provided to NRDR QCDR is true and accurate to the best of my ability. I understand the data submitted for the indicated TIN(s) and/or NPI(s) may be subject to validation by ACR NRDR, including submission of physical records upon request by CMS.

6. I am a physician, practice administrator or other individual authorized to act on behalf of the indicated TIN(s) and/or NPI(s), and in that capacity, I hereby:
   - Certify that I have the authority to provide the selection of measures or activities and confirmation of data completeness level
   - Authorize the ACR NRDR CMS-Qualified Clinical Data Registry (QCDR) to transfer to the Centers for Medicare & Medicaid Services (CMS) performance data on measures or activities selected and confirmed by me for purposes of participation in the Merit-Based Incentive Payment System (MIPS)
   - Certify that I have taken appropriate steps to ensure compliance with all legal requirements applicable to the transmission of patient information

When agreeing and attesting on behalf of NPIs participating in MIPS as individuals and not as a group (GPRO), you must provide written, signed consent by each NPI confirming the authorization of the selection and transfer of performance data to CMS. Documentation must be uploaded in the Attestation section. One document is sufficient.

You can download this document through the MIPS Portal or it is also provided as an attachment on this article. After uploading the document, you may submit the attestation form with your email.

When completing the attestation as a group (GPRO) and not as an individual, you can provide your attestation by providing your email address and submitting the form. No signed document is needed for GPRO reporters.