Medicare ACO - APM Entity Reporting Option 

For performance year 2021 ACOs have the option to report via the APM Performance Pathway (APP) for the purpose of assessing their performance for that program. The program consists of the following: 

  • 3 MIPS CQM/eCQM Quality Measures

    • Quality ID #1 (NQF 0059): Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)

    • Quality ID #236 (NQF 0018): Controlling High Blood Pressure

    • Quality ID #134 (NQF 0418): Screening for Depression and Follow-Up Plan​

  • 2 Claims-Based Measures

    • Hospital-Wide, 30-day All-Cause Unplanned Readmission (HWR)​

    • Risk Standardized:  All-Cause Unplanned Admissions for Multiple Chronic Conditions (MCC)

  • 1 CAHPS for MIPS

Differences between MIPS CQM and MIPS eCQM measure types

  • eCQMs (Electronic Clinical Quality Measures) require structured data to be captured electronically. With an eCQM the patient data is captured in a structured field within the Electronic Health Record (EHR) as part of the clinician workflow.

  • MIPS CQMs (Formerly Registry Measures) typically have some level of manual data collected from the medical record. This allows for review of patient records (electronic and paper documentation) to confirm whether a patient has met the measure requirements.





Step 1:  Complete 2021 Quality Reporting Options (ACO Leadership)

Step 2:  Security Official Training (ACO Leadership)

Step 3:  Planning for 70% of all Payers

Step 4:  Learn the Measures and Patient Selection

Step 5:  Select Data Import Types for all Facilities

Step 6: SFTP Account Setup

Step 7:  Complete Gap Analysis, Scoring and Scorecard Training

Step 8:  Documentation Audits

Step 9: Register  your Clinic



Step 1: Complete 2021 Quality Reporting Options (ACO Leadership)


ACO leadership to complete and submit the Medicare ACO Quality Report Options form. This form will help Health Endeavors understand what is needed to help you report quality measures for the 2021 and 2022 performance years. Once this form is completed please email a copy to

Step 2: Security 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.

  • My Team is used to set-up new users or update access for current users. 

  • Network Manager is used to configure: 

    • Assignment for patients on Commercial Membership Rosters.​

    • Assignment for patients on ACO Attribution List - HALR (Historical Assignment) and QALR (Quarterly Assignment List Report) files.

    • Create Divisions, facilities, locations and providers.




Step 3: Planning for 70% of all Payers


One change for Medicare ACOs that is mandatory for 2021, is the requirement to report the quality measures for 70% of the TOTAL measure denominator. The measure denominator includes ALL patients. This would include Medicare, Medicaid, Medicare Advantage, commercial and non-insured patients. Keep in mind that many patients will not qualify for the 3 APM Entity measures as they are not in the age range or do not have an applicable diagnosis.

We will require your commercial patient rosters or commercial claims data to import these additional patients into Health Endeavors for year-round tracking. 

We are requesting that ACOs collect these additional patients from their practices and send to Health Endeavors via an SFTP download using the Excel template below.

Step 4: Learn the Measures and Patient Selection 


ACO Management Team and all participating providers should get familiar with the measures. 


Patients are selected for a measure using Medicare CCLF claims data.  If the patient had a qualifying encounter as defined in the Medicare CCLF claims data, they would be included in the 70% reporting requirement.


The Measures Overview Document will bring you to a spreadsheet which contains:

  • A 2021 measure summary of CMS Web Interface measures and QPP APM Entity Measures​

  • A 2022 measures summary for the QPP APM Entity Measures

  • Measures Scoring Weight

  • Definition of Data Sources

  • 2021 Data Sources overview by measures

  • Quality Data Code (QDC) Worksheet for using claims (2021 performance Year)

  • Summary of the Administrative Claims Measures

  • FHIR Resources Summary

  • Advanced Care Plan Details



The Measures Specifications is a summary of the quality measures including links to the CMS documents.

Step 5: Select Data Import Types for ALL Facilities


Year-Round Submissions.


This step will help you select your year-round quality measure data sources. The data sources available for selection include:

End-of-Year Submission

  • QRDA Category III (Calculated Report) - Aggregate quality report with a result for a given population and period of time for ACO submission and separate TIN submission (optional).

    • ACOs that submit eCQM quality data via QRDA III files to CMS must de-duplicate the patient level measures data across its ACO providers/suppliers. (Instead of just adding numerators, denominators, etc. and create an aggregate QRDA III file)​

The easiest way to report at the end of the year is to remit the QRDA III file from your EHR as that file will include all patients, regardless of payer. We suggest you take some time and review the Data Sources Flow Chart link below and we can meet with you to discuss commercial patient rosters and commercial claims data. 

Step 6: SFTP Account Setup


Step 7: Complete Gap Analysis, Scoring and Scorecard Training


  • Year-Round Gaps in Care Analysis - Proactive, year-round strategy for identifying, disease and wellness gaps in care significantly improves your quality performance 

  • Year-Round Performance Scoring - Track year-round performance using CPT II codes, QRDA I and SMART on FHIR to avoid poor performance surprises at the end of the year. 

ACO will meet the Shared Savings Program quality performance standard if: 

  • For performance years 2021 and 2022, the ACO achieves a quality performance score that is equivalent to or higher than the 30th percentile across all MIPS Quality performance category scores; and


  • For the 2023 performance year and subsequent performance years, and ACO achieves a quality performance score that is equivalent to or higher than the 40th percentile across all MIPS Quality performance category scores.

ACOs that meet the quality performance standard are eligible to share in savings at the maximum sharing rate, and ACOs in 2-sided models share in losses based on their quality score or at a fixed percentage based on track. ACOs that do not meet the quality performance standard are ineligible to share savings and owe the maximum amount of shared losses, if applicable. 

Step 8:  Documentation Audit


As a qualified registry we are required to work with Medicare on a data validation plan each year when we renew our registry and at the close of the year.  Our Medicare data validation plan requires us to conduct an annual audit of each clinic participating in the registry.


This involves our team submitting a random sample of patients (securely) to the clinic to be audited by the client in the EHR to verify measure documentation.   After the audit of the EHR documentation, we then meet with the clinic to review the findings.

Step 9:  Register your Clinic

The final step is to Register your Clinic by clicking here: 

Clinic Registration Steps Summary:

Frist you will be asked to confirm that your ACO has completed Step One and YOU have reviewed Steps 3-8. All are required to continue. 

Next you will enter your Clinic information. All fields are required.

The final step is to enter your EHR information and capabilities. Please make sure to mark all that apply to your EHR.

Click 'Submit'

At the end of your registration setup you can sign up for additional training if desired. However, we do request you have reviewed all the steps above before scheduling additional training sessions.