CMS Web Interface
The CMS Web Interface Reporting option is only available through the 2024 performance year. Starting in 2025 ACOs will need to choose the Medicare CQM, MIPS CQM or eCQM reporting options.
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Health Endeavors provides a year-round measure data collection solution for Medicare Attributed Patients using data imports such as Quality Reporting Document Architecture (QRDA) Category I files, Medicare Claims, and flat files to answer measures according to our QM Import Chart solution. On a year-round basis the Health Endeavors Quality Registry CMS Web Interface solution identifies care gaps and generates performance scoring at the ACO, TIN and NPI level. A CMS Web Interface patient random sample of 248 patients in each of the 10 measures is delivered in December of the performance year. Reporting for the performance year occurs in January to March of the subsequent year. The Health Endeavors Quality Registry CMS Web Interface Solution includes a reporting optimization tool to submit the best consecutive patient samp
Required Measures
CMS Web Interface requires reporting on 10 quality measures. Click on the link below to view specs for each of these measures.
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10 Web Interface Quality Measures
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Care-2: Falls: Screening for Future Fall Risk
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DM-2: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (9%)
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HTN-2: Controlling High Blood Pressure
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MH-1: Depression Remission at 12 Months
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Prev-5: Breast Cancer Screening
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Prev-6: Colorectal Cancer Screening
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Prev-7: Influenza Immunization
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Prev-10: Tobacco Use: Screening and Cessation Intervention
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Prev-12: Screening for Depression and Follow-up Plan
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Prev-13: Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
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2 Claims-Based Measures
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Hospital-Wide, 30-day All-Cause Unplanned Readmission (HWR)​
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Risk Standardized: All-Cause Unplanned Admissions for Multiple Chronic Conditions (MCC)
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1 CAHPS for MIPS
Eligible Population
CMS Web Interface patients are only your attributed Medicare patients. These are the only patients that will display in the Health Endeavors interfaces for selected periods. Health Endeavors creates these patients from the following CMS files:
HALR: Medicare ACO Historical Assignment file (made available by Medicare on ACO-MS portal once a year before the start of the performance year in December)
QALR: Medicare ACO Quarterly Assignment File (made available by Medicare on ACO-MS portal on a quarterly basis in February, May, August and November)
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CCLF: Medicare ACO Current Claim Line Feed Files (made available by Medicare on ACO-MS portal once a month)
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CMS WI Patient Random Sample: Final reporting population per Medicare
An assigned Medicare patient assigned by claims data assignment or voluntary assignment that has had a claim with a procedure code as defined in the measure specs with a service date between January 1, 202x and December 31, 202x with a provider (NPI) configured in the Quality Participating Providers interface for the given year of service.
Health Endeavors uses the following data sources to answer measures in Health Endeavors.
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Medicare CCLF Claims - Pulling applicable CPT, ICD-10 or HCPCS codes from claims per CMS Web Interface Measure Specification. ACO leadership can choose to use Claims to close a measure with claims or just show applicable information.
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QRDA Category I Files - (Single Patient Report) Individual patient-level report that contains data defined in the measure. (Click here for more QRDA information in the eCQI Resource Center) Files are imported one per month (See the File Processing Calendar)
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Flat File Imports - Health Endeavors can import quality measure answers from a flat file template. These files are imported once per month. (See the File Processing Calendar)
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Spec File Import - Tool available in Health Endeavors for users to import on demand.
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All measure responses can be imported using the tool.​
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Select the module from the sidebar.
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Upload the properly formatted file that contains the patient HICN, MBI or Patient First Name, Last Name and DOB.
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Each measure contains a template to be used for the data.
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An answer legend will be provided for each measure to detail the responses.
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You will be provided a preview of actions to be taken prior to any updates being committed.
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The process is limited to 1000 records per upload.
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Single File Import - Tool available in Health Endeavors for users to import on demand.
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Only positive (performance) measure responses can be uploaded with the tool.​
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Select the module and related question you would like to complete.
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Upload the properly formatted file that contains the patient HICN, MBI or Patient First Name, Last Name and DOB.
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You will be provided a preview of actions to be taken prior to any updates being committed.
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The process is limited to 1000 records per upload.
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Manual Key - Manually Enter quality measure answers in Health Endeavors.
Users will need an SFTP account to send QRDA I or Flat files to Health Endeavors. Please complete our SFTP Form to start the setup process.
Data Sources
Secutiry Official Training (ACO Leadership)
Your Security Official is the top level in the hierarchy of user roles and permissions. This person will manage user account credentials, data import priorities and maintain facility and provider network configuration in the solution. You may have multiple users with the Security Official role.
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My Team is used to set-up new users or update access for current users.
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Quality Import Chart is used to configure data priorities such as EHR and claims.
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Network Manager is used to configure:
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Assignment for patients on Commercial Membership Rosters.​
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Assignment for patients on ACO Attribution List - HALR (Historical Assignment) and QALR (Quarterly Assignment List Report) files.
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Create Divisions, facilities, locations and providers.
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SFTP Account Setup
The participating provider will need a SFTP account to securely transfer quality measure data for QRDA and Flat File imports.
Please complete the SFTP Connection Worksheet and email to support@healthendeavors.com. Once Health Endeavors has completed setup the user will receive an email with login and final setup details.
Health Endeavors Tools
Use our CMS Web Interface Portal for year round Gaps in Care Analysis of the 10 CMS Web Interface Measures
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Proactive, year-round strategy for identifying, disease and wellness gaps in care significantly improves your quality performance. Health Endeavors CMS Web interface Portal allows users to track patients and their Care Gaps using multiple data sources to answer measures.
​Year round Performance Scoring
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Track year-round performance using available data sources to answer measures. Scores are based on the CMS scoring Metrics for these measures.
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Feedback reports are created to give you an overview of what data we are receiving in your Flat Files (BRD) or QRDA files. Each report shows a summary of the measures and answer types we were able to find in your files.
CMS Web Interface Measure Specs
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A summary of each measure with links to the CMS Measure Specs Document and Coding Document.
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Using data from CMS claims and CMS Medicare enrollment and demographics, patients will be selected for each measure sample who meet the denominator criteria and patient eligibility. Patients are sampled into at least one measure, but may be sampled into more than one measure, and will be assigned a number (referred to as the patient’s “rank,” which indicates the order in which the patient was sampled into that measure). All organizations, regardless of size, are required to completely and accurately report on a minimum of 248 consecutively ranked and confirmed Medicare patients for each measure. However, if the pool of eligible sampled patients is less than 248, then an organization is required to report on all sampled patients.
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If possible, an “oversample” will be provided for each measure. This means that each sample will include more patients than are needed to meet the reporting requirement of 248. For the 2021 performance year, 9 of the 10 measures may have an oversample of 616 patients. The PREV-13: Statin Therapy for the Prevention and Treatment of Cardiovascular Disease measure may have an oversample of 750 patients. Please note that the reporting requirement for consecutively ranked and confirmed Medicare patients remains at 248 for PREV-13 despite the larger sample size. If the sampling target of 616 or 750 patients cannot be met for any measure, it will have a smaller sample size that includes all patients who meet measure eligibility. There are denominator exclusion and exception criteria for certain measures that could prevent an organization from meeting the sampling target for a measure.
