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CMS Streamlines its Active Engagement Definition

Effective the 2023 performance year (PY), CMS has streamlined its definition of “active engagement” under the Promoting Interoperability’s Public Health and Clinical Data Exchange Objective. The legacy definition included 3 active engagement options, which have since been consolidated into 2 options. The below table shows how the definitions have changed from the 2022 to the 2023 performance year:

Changes to the Public Health and Clinical Data Exchange Objective:

2022 Final

2023 Final

There are 3 active engagement options:

  • Option 1: Completed Registration to Submit Data
  • Option 2: Testing and Validation
  • Option 3: Production
  1. CMS modified the levels of active engagement by:
    • Combining Options 1 and 2into a single option titled "Pre-production and Validation." Option 3 has been renamed to "Validated Data Production." These changes have resulted in a total of 2 options.
  2. Additionally, MIPS eligible clinicians are required to submit their level of active engagement in addition to requiring a yes/no response for the required Public Health and Clinical Data Exchange measures.
  3. Lastly, clinicians may spend only one performance period at the "Pre-production and Validation" level of active engagement per measure. They must progress to the Validated Data Production level in the next performance period.
    • NOTE: CMS is delaying this requirement until CY 2024.

Upon attesting “yes” to being actively engaged with a clinical data registry, clinicians will also be required to select which active engagement level they fall under (i.e., pre-production and validation OR validated data production).

Lastly, CMS has added that clinicians may only spend one performance year at the "pre-production and validation" level. After the first year clinicians must progress to the “validated data production” level in order to continue claiming credit under this objective.

Dates to Remember

December 31, 2024
CMS deadline to apply for the 2024 Extreme and Uncontrollable Circumstances (EUC) and Promoting Interoperability (PI) hardship exemptions.

January 2025
CMS 2024 MIPS pre-submission audits are conducted.

February 26, 2025
Last day to upload the Health Insurance Claim Form (CMS 1500 Form) and sign the Data Release Consent Forms (DRCF) via the AQUA Registry dashboard.

March 14, 2025
The AQUA Registry’s internal 2024 MIPS submission deadline.

March 31, 2025
CMS’ official 2024 MIPS submission deadline.

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