Every Medicare Shared Savings Program (MSSP) ACO reporting the APM Performance Pathway (APP) has to answer one deceptively simple question each year: at what level do we submit Promoting Interoperability (PI)? The choice between APM Entity-level and individual/group-level reporting looks administrative, but it determines which hardship exceptions CMS will honor, whether your participant TINs can pick their own measure answers, and how your ACO's PI roll-up score is built.
On a recent CMS registry call, a qualified registry raised a detailed set of questions on behalf of an MSSP ACO client in an Enhanced Track Advanced APM whose Qualifying APM Participants (QPs) were applying for PI hardship exceptions due to Certified EHR Technology (CEHRT) issues. CMS's written response clarifies several points that ACOs have been guessing at. Here is what CMS said, and what it means for your PY 2026 submission.
Key Takeaways
- CMS is exercising enforcement discretion on the Shared Savings Program's own PI requirements for PY 2026 — but that relief does not excuse MIPS eligible clinicians in your ACO from MIPS PI reporting.
- If you report PI at the APM Entity level, individual and group hardship exceptions are not applicable. Only APM Entity-level exceptions (such as an approved Extreme and Uncontrollable Circumstances exception) apply.
- At the APM Entity level, every eligible clinician must attest to the same measures and the same answers. No mixing and matching.
- At the individual or group level, each TIN/group chooses its own measures and answers, and individual/group hardship exceptions do count.
- You do not need to submit proof of an approved hardship exception. CMS maintains records of approved exceptions and will reweight the PI category where an exception is granted and the group does not report PI.
PY 2026 Enforcement Discretion: What It Actually Covers
For Performance Year 2026, CMS will exercise enforcement discretion regarding the Shared Savings Program's Promoting Interoperability requirements and the associated public reporting requirement. In practice, CMS will not take compliance actions under 42 CFR §§ 425.216 or 425.218 for PY 2026 if an ACO does not meet the requirements of 42 CFR §§ 425.507 and 425.308(b)(9).
The important limit: this enforcement discretion does not affect the MIPS Promoting Interoperability reporting requirements that apply to MIPS eligible clinicians participating in an ACO. Under the APP, PI carries a 30% weight in the final score — alongside Quality at 50%, Improvement Activities at 20%, and Cost at 0% (42 CFR § 414.1367) — so a missing PI submission still costs you real points even in a year when the Shared Savings Program itself is not enforcing its parallel requirement.
Who Is Excluded or Exempt from PI?
An ACO participant, ACO provider/supplier, or ACO professional is excluded from the Shared Savings Program's requirement to report the MIPS PI performance category if they meet the applicable requirements to be excluded or exempt under 42 CFR part 414, subpart O. Those exclusions include:
- Not exceeding the low-volume threshold, per 42 CFR § 414.1310(b)(1)(iii).
- An eligible clinician (as defined in 42 CFR § 414.1305) who is not a MIPS eligible clinician, per 42 CFR § 414.1310(b)(2).
- Reweighting of the MIPS PI performance category under 42 CFR § 414.1380(c)(2)(i)(C), granted by CMS based on a significant hardship or another type of exception for a specific performance year. Bases for reweighting include being a non-patient facing clinician, a hospital-based clinician, an Ambulatory Surgery Center (ASC)-based clinician, or in a small practice.
The Core Decision: APM Entity Level vs. Individual/Group Level
Reporting at the APM Entity Level
When PI is submitted at the APM Entity level, the ACO must include data from all eligible clinicians who bill under the TIN of an ACO Participant. Only APM Entity-level exceptions are applicable — for example, an approved MIPS Extreme and Uncontrollable Circumstances (EUC) exception granted at the APM Entity level.
The ACO may not exclude eligible clinicians from its PI submission on the basis of those clinicians' individual- or group-level exceptions. If hardship exceptions are granted at the individual or group level, they are only applicable if reporting is actually done at that level. CMS identifies which groups are included based on the reporting level and on the eligibility/exclusion status of each clinician or group.
This matters more than it may first appear, because APM Entities cannot apply for a PI hardship exception in the first place. The 2026 MIPS PI Hardship Exception Application Guide is explicit that APM Entities reporting the APP or traditional MIPS can't submit a PI hardship exception application on behalf of the entire APM Entity. So an ACO with a meaningful number of QPs facing CEHRT problems has, at the APM Entity level, no way to carve those clinicians out of an aggregated submission on the basis of their own hardship exceptions. An APM Entity-level EUC exception is the entity-level route CMS identified. (The subpart O exclusions above — low-volume, non-MIPS eligible clinician status, and the § 414.1380(c)(2)(i)(C) reweighting bases — still operate on their own terms.)
Reporting at the Individual or Group Level
When PI is reported at the individual or group level, individual and group-level exceptions may be applicable. CMS tracks hardship exceptions through the reporting mechanism: if a hardship exception is granted and the group does not report PI, CMS will reweight the PI category accordingly.
You do not have to submit proof of the exception at submission. CMS maintains records of approved exceptions.
Can Different QPs Report Different Measures?
This was the question with the sharpest answer. If PI is submitted at the APM Entity level, all eligible clinicians must report the same measure options and the same answers. The ACO cannot mix and match measure options or answers across QPs.
Two concrete examples CMS addressed:
- All clinicians must attest to the same Health Information Exchange option — for example, HIE_6 (bi-directional exchange), HIE_1/HIE_4 (sending and receiving electronic referral loops), or HIE_5 (enabling exchange under TEFCA). One QP cannot choose HIE_6 while another chooses HIE_1 and HIE_4.
- All clinicians must select the same registry option for PI_PHCDRR_1 (immunization registry) — one QP cannot report option 1 (pre-production) while another reports option 2 (validated data production).
If reporting is done at the group level, each group can select its own measure options and answers, as long as they meet the requirements for that group.
APM Entity vs. Group-Level Reporting at a Glance
| Consideration | APM Entity Level | Individual / Group Level |
|---|---|---|
| Who must be included | All eligible clinicians billing under the TIN of an ACO Participant | Each TIN/group submits for its own clinicians |
| Individual/group hardship exceptions | Not applicable — cannot be used to exclude clinicians | Applicable; CMS reweights when granted and PI is not reported |
| APM Entity-level exceptions (e.g., EUC) | Applicable | Not the relevant level |
| Measure selection | Identical measures and answers across all clinicians | Each group selects its own measures and answers |
| Proof of exception at submission | N/A — individual/group exceptions do not apply at this level | Not required; CMS maintains records of approved exceptions |
How the PI Roll-Up Score Works
CMS confirmed there is no explicit disadvantage to reporting PI at the individual group level for each TIN participating in the MSSP ACO. The PI roll-up score is calculated as a weighted average of the highest score attributed to each MIPS eligible clinician in the APM Entity, based on their individual or group reporting.
Read carefully, this is a caveat as much as a reassurance: CMS said there is no explicit disadvantage, but the roll-up is a weighted average, not a simple pass/fail. CMS did not elaborate on how reweighted clinicians factor into that average, so ACOs should not assume group-level reporting mechanically produces a higher aggregate score. Model both scenarios against your own participant mix before committing.
Operational Checklist for PY 2026
- Inventory CEHRT readiness by TIN. Identify which participant TINs have certified EHR technology issues that could support a hardship exception before you commit to a reporting level.
- File hardship exception applications at the right level. Individual clinicians, groups, and virtual groups reporting traditional MIPS, an MVP, or the APP may apply, as may an authorized third-party intermediary — but not the APM Entity. The 2026 exception application window closes December 31, 2026 at 8 p.m. ET.
- Decide the reporting level early. If a meaningful share of your QPs will have approved individual/group hardship exceptions, APM Entity-level reporting will pull them back in. Group-level reporting preserves those exemptions.
- If reporting at the APM Entity level, standardize measure answers now. Confirm every participating clinician can attest to the same HIE measure and the same public health registry options. Review the 2026 MIPS Promoting Interoperability measures before locking in your selections (note that page reflects the 25% PI weight under traditional MIPS; under the APP the category is weighted at 30%).
- Do not plan to submit exception documentation. CMS applies approved exceptions from its own records; keep your approval confirmations for internal audit purposes only.
- Verify eligibility and special status. Low-volume threshold, non-MIPS eligible clinician status, non-patient facing, hospital-based, ASC-based, and small practice status all change the picture before you report a single measure.
Resources to Review
- 2026 APP Toolkit — available in the third quarter of PY 2026 in the QPP Resource Library
- 2026 MIPS Promoting Interoperability Quick Start Guide — available in the QPP Resource Library
- Shared Savings Program Requirements to Report Objectives and Measures for the MIPS Promoting Interoperability Performance Category (CMS FAQ)
How MDinteractive Can Help
As a CMS-approved Qualified Registry and QCDR for ACO APP reporting, MDinteractive supports MSSP ACOs across the full APP submission — Quality, Improvement Activities, and Promoting Interoperability — at both the APM Entity, individual or group level. We help ACOs model the reporting-level decision against their participant TINs' actual exception and special status picture, standardize PI attestations where aggregation is the right call, and keep the submission clean where it isn't.
Schedule an MDinteractive ACO Reporting Demo to review your PY 2026 Promoting Interoperability strategy before the submission window opens.