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Understanding Your MIPS Eligibility Status

Posted on November 19, 2019

The Quality Payment Program (QPP) Participation Status Tool allows clinicians to view their eligibility status for both the Merit-based Incentive Payment Program (MIPS) and the Alternative Payment Model (APM) program. Clinicians can enter their individual National Provider Identifier (NPI) into the tool to learn if they are required to report MIPS by performance year or if they are a Qualifying APM Participant (QP) or Partial QP. CMS recently updated the tool with information about clinicians’ APM status and is expected to update MIPS eligibility in November. MIPS eligible clinicians who do not report MIPS this year will receive an automatic 7% penalty on their Medicare Part B payments in 2021, so it is important to understand what their eligibility status means so they can protect their Medicare reimbursement.

MIPS Eligibility

The QPP Participation Status Tool displays your current MIPS eligibility and if you are eligible to report MIPS at the individual and group level. MIPS eligibility is based on a clinician’s individual NPI and associated Tax Identification Numbers (TINs). This means you could be required to report MIPS for more than one practice.

The CMS tool lists any practice(s) your NPI is associated with and if you have a special status designation, such as hospital-based, non-patient facing or small practice. It also includes information about your ability to opt-in to MIPS.

Remember, you need to review your eligibility for each TIN/practice for which you submit Medicare claims. It is important to check both your MIPS participation status and your APM participation status.

You can check your MIPS eligibility directly from your MDinteractive account.  Once you add your NPI and TIN to the homepage dashboard, just click the blue “Check MIPS Eligibility” underneath your name. Next select “click for more info” to be taken to the QPP Participation Status website.

MIPS Eligibility as an Individual and a Group

When you check your MIPS participation status, it will show your MIPS eligibility as an individual clinician and as a group.

  • If you are MIPS eligible as an individual, you are required to report MIPS to avoid the 7% penalty. You may have the option to report MIPS as a group to avoid the penalty if there are 2 or more clinicians in your TIN.

  • If you are not MIPS eligible as an individual or as a group, you won’t be penalized for not reporting MIPS. You may be eligible to opt-in to the program or voluntarily report MIPS.

  • If you are not MIPS eligible as an individual, but are MIPS eligible as a group, your data needs to be included if your TIN chooses to report as a group. You won’t be penalized if your TIN decides not to report as a group.

How CMS Determines Your Eligibility

MIPS Eligible Clinician Types

There are several “types” of providers that are considered “MIPS eligible clinicians” in 2019 and are included in the program if they bill Medicare Part B claims:

  • Physicians (including doctors of medicine, doctors of osteopathy, osteopathic practitioners, doctors of dental surgery, doctors of dental medicine, doctors of podiatric medicine, doctors of optometry, and 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 nutritional professionals

MIPS Exclusions

If you're exempt from MIPS in 2019, you are not required to report MIPS and you will not receive a MIPS penalty. You are excluded from MIPS in 2019 if you:

  • Are not a MIPS eligible clinician type
  • Enroll in Medicare for the first time in 2019
  • Are a Qualifying APM Participant (QP) or Partial QP
  • Don’t exceed the low-volume threshold criteria:

Bill $90,000 or less in Medicare Part B covered professional services; OR

See 200 Medicare Part B patients or less; OR

Provide 200 or less covered professional services to Medicare Part B patients

MIPS Determination Period

CMS reviews your Medicare Part B claims and PECOS data from two 12-month periods to determine the volume of care you provide to Medicare beneficiaries:


Posted on QPP Status Tool

October 1, 2017 - September 30, 2018

Initial eligibility released in February of 2019

October 1, 2018 - September 30, 2019

Final eligibility expected to be released in November of 2019

You must exceed all 3 of the low-volume threshold criteria during both parts of the MIPS determination period to be included in MIPS. Your eligibility could change during the second period for reasons such as joining or leaving a practice, so it is important to check your status again at the end of this year. However, if you are not MIPS eligible for your existing practice during the first review period, you won’t become MIPS eligible for that same practice during the second review period.

Opt-In Option

The CMS tool provides information on your ability to opt-in to MIPS. Clinicians or groups would have the ability to “opt-in” to MIPS if they meet or exceed one or two, but not all, of the low-volume threshold criteria. If you “opt-in” to the MIPS program you will be subject to neutral, negative or positive payment adjustments based on your MIPS performance and final score. Once you elect to “opt-in”, the decision is irreversible for the current performance year.

Remember, if you are not required to report MIPS, you can choose to report MIPS voluntarily without choosing to “opt-in”. If you voluntarily report MIPS you will not be subject to any payment adjustments. The benefit of voluntarily reporting MIPS is you will receive performance feedback and are eligible for data to be published on Physician Compare.


The QPP Participation Status Tool will also indicate if you participate in an APM. An APM is a payment approach that gives added incentives to provide high quality and cost-efficient care. APMs can be designated as MIPS APMs or Advanced APMs.

  • MIPS APMs follow a different path than “standard” MIPS and have different scoring criteria. Eligible clinicians in a MIPS APM will receive MIPS payment adjustments and MIPS-APM specific rewards.
  • Advanced APMs must meet different requirements, including taking on some risk related to patient outcomes. Qualifying participants in an Advanced APM are exempt from MIPS payment adjustments and can qualify for a 5% lump sum bonus.

CMS reviews APM participation 3 times during the performance year. During each review period, CMS will determine if you are a Medicare Qualifying APM Participant (QP) or Partial QP and exempt from MIPS reporting.

APM Snapshot

Posted on QPP Status Tool

January 1, 2019 – March 31, 2019

July 2019

January 1, 2019 – June 30th, 2019

October 2019

January 1, 2019 – August 31, 2019

December 2019

Below are examples of different scenarios that might appear on the QPP tool if you participate in an APM and how each could affect your MIPS eligibility.

  • If you participate in an Advanced APM (for example Next Generation Accountable Care Organization (ACO) or Sharing Savings Program - Track 2) and are a Qualifying APM Participant (QP) or Partial QP you are not required to report MIPS:

  • If you participate in certain types of MIPS APMs (for example Medicare Shared Savings Program ACO – Track 1), you may be required to submit Promoting Interoperability (PI) data at the group level (unless otherwise exempt) and the APM entity should submit Quality data. You should contact the APM to confirm your reporting requirements:

  • If you participate in a MIPS APM, but are considered a “preferred provider”, you will not be scored under the APM scoring standard and may be required to report MIPS unless otherwise exempt:

  • If you bill with multiple TINs, your status will be noted for each practice. If you are not a QP, you may be required to report MIPS for one of your practice TINs and required to follow the APM rules for another practice TIN:

Next Steps

CMS updates the QPP Participation Status Tool throughout the performance year. You can check whether your are required to report MIPS or are part of an APM by entering your NPI into the tool. It is important to check your MIPS eligibility and APM status for each TIN/practice listed on the CMS website. We have also made it easy for you to check your MIPS eligibility status directly from your MDinteractive account dashboard. CMS will update your MIPS eligibility for 2019 at the end of this year, so you should confirm your status again in December. Understanding your MIPS eligibility and reporting options is important to ensure you avoid the -7% MIPS penalty.

MIPS Eligibility MIPS Eligible Clinicians QPP Participation Status Tool Low Volume Threshold APM

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