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How MIPS Eligibility is Determined
Your eligibility status is based on your:
- National Provider Identifier (NPI) and
- Associated Taxpayer Identification Numbers (TINs).
A TIN can belong to:
- You, if you’re self-employed,
- A practice, or
- An organization like a hospital.
When you reassign your Medicare billing rights to a TIN, your NPI becomes associated with that TIN. This association is referred to as a TIN/NPI combination.
If you reassign your billing rights to multiple TINs, you’ll have multiple TIN/NPI combinations.
We evaluate each TIN/NPI combination for MIPS eligibility and use TINs to evaluate practices for eligibility.
We review past and current Medicare Part B claims and Provider Enrollment, Chain, and Ownership System (PECOS) data for clinicians and practices twice for each performance year. Each review, or “segment,” analyzes a 12-month period.
Analysis of data from the first segment is released as preliminary eligibility. Analysis of data from the second segment is reconciled with the first segment and released as the final eligibility determination.
Clinicians and practices generally must exceed the low-volume threshold during both segments of the MIPS Determination Period to be eligible for MIPS.
_Exception: Eligibility will be based solely on segment 2 data when a TIN or TIN/NPI combination is newly established during segment 2 of the MIPS Determination Period._
Learn more about the MIPS Determination Period
The low-volume threshold includes 3 aspects of covered professional services:
- Allowed charges
- Number of Medicare patients who receive covered professional services
- Number of services provided
You must participate in MIPS (unless otherwise exempt) if, in both 12-month segments of the MIPS Determination Period, you:
- Bill more than 0,000 for Medicare Part B covered professional services, and
- See more than 200 Medicare Part B patients, and;
- Provide more than 200 covered professional services to Medicare Part B patients.
If you start billing Medicare Part B claims under a practice’s TIN during segment 2, your eligibility at that practice will be based solely on the results from analysis of segment 2 data.
You're eligible to participate in MIPS if you're a MIPS eligible clinician type and you also meet all the other requirements in the next section. If you’re not one of the clinician types listed below, you’re excluded from reporting and the MIPS payment adjustment:
- Physicians (including doctors of medicine, osteopathy, dental surgery, dental medicine, podiatric medicine, and optometry)
- Osteopathic practitioners
- Chiropractors
- Physician assistants
- Nurse practitioners
- Clinical nurse specialists
- Certified registered nurse anesthetists
- Physical therapists
- Occupational therapists
- Clinical psychologists
- Qualified speech-language pathologists
- Qualified audiologists
- Registered dietitians or nutrition professionals
- Clinical social workers
- Certified nurse midwives
There are different ways to become a MIPS eligible clinician, depending on whether you’re reporting to MIPS as an individual, as part of a group or as part of a virtual group. If you don’t meet the requirements in this section, you’re exempt from MIPS.
Learn more about what to do next as a MIPS eligible clinician
MIPS Eligibility: INDIVIDUAL
In order to be MIPS eligible as an individual clinician, you must:
- Be identified as a MIPS eligible clinician type on Medicare Part B claims,
- Have enrolled as a Medicare provider before 2023,
- Not be a Qualifying Alternative Payment Model Participant (QP), and
- Exceed the low-volume threshold as an individual.
If you’re MIPS eligible as an individual, you’re required to report to MIPS.
MIPS Eligibility: GROUP
In order to be MIPS eligible as part of a group, you must:
- Be identified as a MIPS eligible clinician type on Medicare Part B claims,
- Have enrolled as a Medicare provider before 2023,
- Not be a QP, and
- Be associated with a practice that exceeds the low-volume threshold.
If a practice is MIPS eligible, it may report for all clinicians in the practice as a group. In that case, you'll receive a score and a payment adjustment based on that group's reporting, unless a higher final score can be attributed to you from individual or APM Entity participation. (Note that clinicians in a virtual group always receive the virtual group's final score.)
For a practice to be MIPS eligible, it must:
- Exceed the low-volume threshold and,
- Have at least one clinician who:
- Is identified as a MIPS eligible clinician type on Medicare Part B claims,
- Enrolled as a Medicare provider before 2023, and
- Isn't a QP.
Clinicians who are both MIPS APM participants and who are MIPS eligible at the individual or group level can report to traditional MIPS and/or report to MIPS via the APM Performance Pathway (APP).
MIPS Eligibility: VIRTUAL GROUP
To be MIPS eligible in a virtual group, you must:
- Be identified as a MIPS eligible clinician type on Medicare Part B claims,
- Have enrolled as a Medicare provider before 2023,
- Not be a QP, and
- Participate in a practice that exceeds the low-volume threshold and is part of a virtual group.
If you’re MIPS eligible in a virtual group, the virtual group is required to report your data and you’ll receive a final score and MIPS payment adjustment based on the virtual group’s reporting.
If you’re opt-in eligible, then you aren't required to participate in and report to MIPS, but during the submission period, you may elect to opt-in to MIPS.
If you elect to opt-in, you’ll:
- Be considered a MIPS eligible clinician and be required to report data to MIPS,
- Receive performance feedback,
- Receive a MIPS payment adjustment (positive, negative, or neutral),
- Be eligible to have your data publicly reported on the Doctors and Clinicians section of Care Compare (formerly “Physician Compare”), and
- Be assessed in the same way as MIPS eligible clinicians who are required to participate in MIPS.
MIPS Eligibility: INDIVIDUAL Opt-in Option: Opt-in eligible as individual
You can elect to opt-in to MIPS as an individual if you:
- Are identified as a MIPS eligible clinician type on Medicare Part B claims,
- Have enrolled as a Medicare provider before 2023,
- Aren't a QP, and
- Exceed 1 or 2 of the 3 low-volume threshold criteria as an individual.
MIPS Eligibility: GROUP Opt-in Option: Opt-in eligible as group
If a practice is opt-in eligible, they can elect to opt-in and report as a group on behalf of all clinicians in the practice.
A practice is opt-in eligible as a group if the practice:
- Has at least one clinician who:
- Is identified as a MIPS eligible clinician type on Medicare Part B claims,
- Enrolled as a Medicare provider before 2023,
- Isn't a QP.
- Exceeds 1 or 2 of the 3 low-volume threshold criteria at the group level.
If your practice opts-in as a group, you'll receive a score and a payment adjustment based on that group's reporting (unless you also elect to opt-in as an individual, in which case you'll receive the higher of the 2 scores). You don't need to make a separate opt-in election for clinicians to receive the group's score and payment adjustment.
You can voluntarily report to MIPS as an individual or group in the following circumstances:
- You (individual or group) are opt-in eligible and elect to voluntarily report.
- You (individual or group) are exempt from MIPS (neither eligible nor opt-in eligible).
You can’t voluntarily report if you’re eligible for MIPS.
If you voluntarily report for MIPS, you’ll:
- Receive limited performance feedback, allowing you to prepare for future years, and;
- Be eligible to have your data published on the Doctors and Clinicians section of Care Compare (formerly “Physician Compare”).
If you voluntarily report to MIPS, you WON’T:
- Receive a payment adjustment based on the data submitted, or
- Be included in the calculation of MIPS measure benchmarks.
If you sufficiently participate in an Advanced APM Entity, you may achieve QP status, which excludes you from MIPS participation. If you don't achieve QP status and are otherwise considered a MIPS eligible clinician, you'll need to participate in MIPS. Clinicians who achieve Partial QP status only need to participate in MIPS if they (or their APM Entity) submit an election to do so.
We'll make QP determinations using each Advanced APM Entity’s Participation List at 3 snapshot dates: March 31, June 30, and August 31.
You may be required to report to MIPS if you bill Medicare Part B claims under a new practice/TIN in segment 2 of the MIPS Determination Period or join an APM Entity in later snapshots.
Changing your provider type or specialty code from segment to segment of the determination period could affect your eligibility.
If you stop billing Medicare Part B claims under a specific practice (TIN) during segment 1, and have no Medicare Part B claims billed during segment 2 for that practice, you'll be removed entirely from the practice’s list of connected clinicians.
You won't be eligible to participate if you fall below all 3 elements of the low-volume threshold in segment 2 of the MIPS Determination Period.
We assess eligible clinicians for QP Status at the APM Entity level, based on either the payment amount or patient count method. We assess an eligible clinician for QP status individually only when the Advanced APM Entity includes an eligible clinician on an Affiliated Practitioner List, or when the eligible clinician participates in multiple Advanced APM Entities and doesn't achieve QP status at the APM Entity level. Calculations for eligible clinicians on an Affiliated Practitioner List will be published each snapshot. Individual QP scores will be calculated for those in more than one APM Entity; the most favorable of the scores will be published as part of the third snapshot results.
You'll maintain your QP status unless the Advanced APM Entity’s participation in the Advanced APM is voluntarily or involuntarily terminated prior to the end of the QP performance period.
Your QP status can change at each APM snapshot depending on whether the APM Entity or individual score meets or exceeds the QP thresholds. A clinician doesn't need to attain QP status at each of the 3 snapshots. If a clinician achieves QP status at any snapshot, the clinician will maintain their QP status for the performance year.