MIPS CQM

Historically, TMIP ACO reported 10 measures through the CMS Web Interface in the past 10 years on behalf of the participating providers. Beginning with the 2021 reporting year, ACOs could report quality data via the new APM Performance Pathway (APP) and could choose to actively report either the 10 measures under the CMS Web Interface or 3 MIPS eCQMs/CQMs.

The CMS Webinterface reporting option has been sunset after the 2024 Performance Year. As a result, ACOs will no longer be able to use the Web Interface as a submission method beginning with the 2025 performance year.

For the 2025 performance year and subsequent performance years, ACOs will be required to actively report quality data on the required eCQM/MIPS CQM measures via the APP (Refer to Table 1). In addition, ACOs will be required to field the CAHPS for MIPS Survey, and CMS will calculate measures using administrative claims data. All measures will be included in the calculation of the ACO’s MIPS quality performance category score.

To comply with CMS regulations, due to the large amount of EHRs, TMIP will be moving forward with the MIPS CQM option. We have selected MD Interactive as our vendor. You can find more information at Medicare Shared Savings Program - Reporting MIPS CQMs and eCQMs in the Alternative Payment Model Performance Pathway (APP): Guidance (cms.gov)

Table 1: Quality Measures in the APP Plus Quality Measure Set for Shared Savings Program ACOs

MD Interactive

TMIP Board has approved to engage with MD Interactive, data aggregating CMS certified vendor. MD Interactive has over 25 years of experience working with healthcare providers of all sizes and in all settings, MDinteractive provides one-stop solution for submitting Quality, Promoting Interoperability and Improvement Activity data to CMS to fulfill requirements of the Merit-based Incentive Payment System (MIPS).

How MDinteractive can help:

• Assistance with compliance: MDinteractive can help ACOs comply with the data reporting requirements while supporting your ability to make informed decisions on how best to improve the quality of care for Medicare patients within your organizations.

• One-stop reporting for required Quality CQM's: Measure #1, #134, #236, and #112 (new measure added for 2025) can be reported via MDinteractive.

• Flexible data input: MDinteractive can accept various types of quality data files and also provides software “tools” that can be used to build quality reports.

• Flexible submission choices: MDinteractive can accommodate data at the ACO level, by participating TIN, or at the individual clinician level.

• Monitoring performance: MDinteractive software allows you to plan, track and optimize your quality data reporting and performance through an interactive dashboard. You will have the ability to monitor your performance at the ACO, TIN and clinician level throughout the year and make necessary quality improvements within your organization to maximize your incentive payments.

• Responsiveness to changes within your organization: MDinteractive has extensive experience aggregating quality data from multiple EHRs before submission to CMS.

• Hands-on customer support at all stages in the reporting process: At MDinteractive, our seasoned team will help you navigate through the reporting process from beginning to end and offer advice on how to maximize your reimbursement and avoid sharing losses.

Security:

MDinteractive maintains high security standards and holds a SOC 2 certification for security. In the event of a data breach, MDinteractive will notify Torrance Memorial in accordance with the terms of the Business Associate Agreement (BAA) and HIPAA regulations. The notification will include, to the extent possible, the identification of each individual whose unsecured Protected Health Information (PHI) has been disclosed. Additionally, it will provide any other relevant information that Torrance Memorial is required to include in notifications to individuals and other entities, as mandated by the Breach Notification Rule under HIPAA. Furthermore, MDinteractive will undertake corrective action to remedy any deficiencies and comply with any actions required by applicable laws and regulations regarding unauthorized uses or disclosures of PHI.

Project Timeline: January 16, 2026, Deadline to submit Final, Full Year QRDA 1 data

Important Notice: TMIP/ACO

Method: 

QRDA 1 files for 2 or more measures. Extract all remaining measures using alternative methodologies.

This submission represents the final data submission for the 2025 performance year. To ensure timely and accurate year-end reporting to CMS, it is important that all required data be submitted within this window.

What You Need to Do

1. Prepare your final end-of-year 2025 QRDA 1 file(s):
   • Include data for all clinicians in your practice from January 1, 2025 – December 31, 2025, for the following metrics:
     1. CMS2: Preventive Care and Screening: Screening for Depression and Follow-Up Plan
     2. CMS122: Diabetes: Glycemic Status Assessment Greater Than 9%
     3. CMS125: Breast Cancer Screening **new metric added for 2025**
     4. CMS165: Controlling High Blood Pressure
   • For guidance on generating QRDA 1 file from your EHR, please refer to your EHR support resources.
2. Upload your files by January 16, 2026: 
   • Use this secure link to upload the files: Submit QRDA 1 Files
   • MDinteractive, a CMS-qualified registry, will compile and submit your data to CMS.    

Submission Short-Term Relaxation Rule:

For 2025, the TMIP Board has approved a temporary relaxation. You must submit a QRDA I file for at least two of the required measures. If your EHR cannot generate QRDA I for the remaining measures, you may submit billing files instead. Please note, this exception is temporary. For full details, refer to the TMIP Board email sent on July 3, 2025.

TMIP Operations Support Specialist

Mahenaz

E-mail: Mahenaz@tmmc.com

Phone: (424)435-7209

MD Interactive's contact information

E-mail: support@mdinteractive.com

Address: 945 Concord St., Framingham, MA 01701

Phone: (800)634-4731

Fax: 866-251-4069

Customer support hours: Monday - Friday, 9 a.m.-5 p.m. EST

CMS contact information

Email: SharedSavingsProgram@cms.hhs.gov with ACO ID: 4964 and ACO name: Torrance Memorial Integrated Physicians, LLC.