The following is guidance for initial correspondence from ACOs to their member TIN participants with the goal of facilitating project momentum and delineating participant responsibilities. The topics below are meant to assist with communication from the ACO to member TINs:
Education
Include a few brief sentences about the program for the target reporting year and that the ACO is beginning to submit data according to APP requirements which is different from how practices may have previously reported in the past (e.g., MIPS, CMS Web Interface, etc.). The ACO should expect to communicate with member TINs throughout the year to reiterate reporting requirements. APP reporting requires data on all patients and all payers for the following measures:
001 (CMS 122) - Diabetes: Glycemic Status Assessment Greater Than 9%
112 (CMS 125) - Breast Cancer Screening
113 (CMS 130) - Colorectal Cancer Screening (new for 2026!)
134 (CMS 2) - Preventive Care and Screening: Screening for Depression and Follow-up Plan
236 (CMS 165) - Controlling High Blood Pressure
Note: The ACO may choose to report the temporary Medicare CQM collection type which requires reporting data on the measures listed above for Medicare beneficiaries (rather than all patients/all payers).
Roles and Responsibilities
Indicate that ACO leadership has engaged with Patient360, a Qualified Registry, to support your submission of data for the APP program. Patient360 will be ingesting the data you send, providing a performance dashboard to monitor uploaded data, and then submitting the data to CMS according to statutory requirements. Member TINs will be responsible for sending their data to Patient360, providing the expected number of patients and performance rates for each measure based on their EHR source system, and monitoring data throughout the performance period with ACO and Patient360 support.
Recommended Timeline and Action Items
During the month of February it is recommended that the ACO identify 1-2 staff members from each TIN who have the technical and operational skills to liaise with their EHR and upload the data to Patient360. These staff members will be given access to the Patient360 portal where data will be sent and can be monitored. The ACO will need to provide name(s) and email addresses for each user in order for Patient360 to create their account. Note: You can have multiple users per TIN. Each user will be provided with a unique invitation token from Patient360 that will allow them access our portal. The TIN users will have the option to upload data to Patient360 through sFTP or directly in the portal via Drag & Drop. Instructions on both of these options are linked in the Data Submission section below.
In March & April, once the export method of data has been determined by your TIN, you should begin using that method to send (or upload) Patient360 your data for the 5 measures listed above.
Throughout summer and fall, member TINs should be logging into Patient360 to monitor their data progress and performance. The ACO should also be monitoring data uploads and performance on a weekly basis, reaching out to member TINs if data uploads and/or performance does not meet ACO standards.
The ACO will also receive 4 feedback reports from Patient360 throughout the performance period after your initial data is flowing.
Data Submission
Engage each member TIN to determine their reporting capabilities. Inquire whether their EHR is ONC CEHRT certified and is able to produce QRDA I files for the following eCQM measures:
001 (CMS 122) - Diabetes: Glycemic Status Assessment Greater Than 9%
112 (CMS 125) - Breast Cancer Screening
113 (CMS 130) - Colorectal Cancer Screening (new for 2026!)
134 (CMS 2) - Preventive Care and Screening: Screening for Depression and Follow-up Plan
236 (CMS 165) - Controlling High Blood Pressure
If the EHR is able to produce QRDA I files:
Determine if there is a fee from the EHR vendor
Establish a timeline as to when they can produce QRDA I files for the target reporting year
Determine whether the TIN prefers to manually upload QRDA I files into the Patient360 portal or whether the TIN has the ability to upload via sFTP
If the EHR is not able to produce QRDA I files:
- Instruct participant TIN that CQM (all patients/all payers) or MCQM (Medicare beneficiaries only) data can be loaded manually using the Patient360 CSV file templates