Download as PDF

PROMOTING INTEROPERABILITY FOR MSSP ACOs:
PREPARING FOR CEHRT REQUIREMENTS

Updated: January 2026

Background

To be considered an Advanced Alternative Payment Model (APM), a payment model must meet criteria such as requiring use of certified electronic health record technology (CEHRT), basing payments in part on quality measures comparable to those in the Merit Based Incentive Payment System (MIPS), and requiring Advanced APMs to meet certain financial and nominal risk criteria. For many years, the Medicare Shared Savings Program (MSSP) has used an annual CEHRT attestation to fulfill this requirement. Previously, ACOs in Advanced APM tracks would attest annually that at least 75 percent of their eligible clinicians are using CEHRT. ACOs in non-Advanced APM tracks (i.e., MIPS APM tracks) also were required to certify annually that at least 50 percent of eligible clinicians participating in the ACO use CEHRT to document and communicate clinical care to their patients or other health care providers. Prior to 2018, CMS assessed the use of CEHRT through a quality measure.

In the final 2024 Medicare Physician Fee Schedule rule, CMS established a new requirement effective Performance Year (PY) 2025, which will instead require all MSSP eligible clinicians in the ACO to report Promoting Interoperability (PI) measures and earn a MIPS PI performance category score, unless an applicable MIPS exclusion applies. NAACOS continues to advocate for the removal of this burdensome requirement.

Promoting Interoperability Requirements

The Promoting Interoperability performance category is used in MIPS to assess clinicians’ meaningful use of CEHRT. Hospitals are assessed similarly through the Hospital PI requirements. For PY 2025 and subsequent years, eligible clinicians must submit data collected for the required measures in each of the five objectives (unless an applicable exclusion is claimed) for the same 180 continuous days during the calendar year. The PI performance category assesses clinicians in these areas:

1. Electronic prescribing – generating and transmitting permissible electronic prescriptions.
2. Health information exchange – providing a summary of care, supporting electronic referrals, bi-directional exchange of health information, and enabling exchange under the Trusted Exchange Framework and Common Agreement (TEFCA).
3. Provider to patient exchange – providing timely electronic access of health information to patients.
4. Public health and clinical data exchange – sharing data with a public health agency or registry.
5. Protect patient health information – conducting a security risk assessment and adhering to the Safety Assurance Factors for EHR Resilience (SAFER) Guide.

To successfully report, you must also provide your EHR’s CMS identification code from the Certified Health IT Product List (CHPL) and submit a “yes” to the following attestation statements:

• Actions to Limit or Restrict Compatibility or Interoperability of CEHRT (formerly named prevention of information blocking) attestation
• Office of the National Coordinator for Health Information Technology (ONC) Direct Review attestation
• Security Risk Analysis measure
• High Priority Practices Safety Assurances Factors for EHR Resilience (SAFER) Guide measure (a “no” answer will no longer satisfy this measure starting in PY 2024)
• ONC-Authorized Certification Bodies (ACB) Surveillance Attestation (optional)

ACO Reporting Requirements

All participant practices or clinicians must report PI
Unless otherwise excluded under MIPS exclusion rules, all practices and participants in an MSSP ACO must report MIPS PI measures and requirements at the individual, group, virtual group, or APM entity level and earn a performance category score.

An ACO participant, provider/supplier, or professional is excluded from these requirements if they meet MIPS exclusion criteria outlined in 42 CFR part 414 subpart O. This includes exclusions such as the MIPS low volume threshold, those not meeting the definition of a MIPS eligible clinician, and those that qualify for reweighting of the MIPS PI performance category to zero (414.1380 (c)(2)). CMS issued guidance to clarify that additional important exclusions apply, such as the small practice exclusion, non-patient facing, hospital-based, and ASC-based exclusions.

According to the Quality Payment Program (QPP) website, clinicians with one of the special statuses will receive automatic reweighting for PI. For PY 2025 and subsequent years these include:

• Ambulatory surgical center (ASC)-based;
• Hospital-based;
• Non-patient-facing; and
• Small practice (15 or fewer clinicians).

Individuals, groups, and virtual groups can apply for a MIPS PI performance category hardship exception by December 31 of the relevant performance year for one of the following reasons (subject to approval):

• MIPS clinician using decertified EHR technology
• Insufficient internet connectivity
• Extreme and uncontrollable circumstances
• Lack of control over the availability of CEHRT

CMS encourages ACOs to check their participants’ MIPS eligibility before and during the performance year to ensure they have up to date eligibility information at qpp.cms.gov. NAACOS continues to call on CMS to provide more guidance to ACOs regarding clinicians exempt or excluded from PI reporting for the ACO to reduce burden.

More information is also available on the CMS QPP website.

How to Submit Data

There are three ways to submit data:

• Sign in and attest
• Sign in and upload
• Direct submission via Application Programming Interface (API), only applicable to third party intermediaries such as a registry

APM Entities can have participants report at the individual or group level. While CMS states the ACO can report PI as an APM entity, it is not clear how that would be accomplished, particularly for those ACOs with multiple Tax Identification Numbers (TINs) with multiple EHRs and instances of EHRs. In a recent meeting with NAACOS, CMS noted that the agency is currently establishing a process for ACOs to be able to report PI at the APM entity-level and to submit hardship exemption applications on behalf of their participating practices. CMS notes the agency will provide more guidance in this area as soon as possible. In the meantime, ACOs should have practices and clinicians report PI and be prepared to document each ACO participant’s CMS EHR Certification ID and screenshots of submissions (or actual submission files). See the ONC Certified Health IT Product List search for more information. 

Reporting Options by Submitter Type
Submitter Type	Sign In and Attest	Sign In and Upload	Direct Submission (API)
MIPS Eligible Clinician	Yes	Yes	No
Representative of a practice, virtual group, or APM Entity	Yes	Yes	No
Third Party Intermediary	No	Yes	Yes

Scoring
CMS will calculate the performance rate for each measure using the numerators and denominators submitted and then multiply the performance rate by the total points available for the measure. For scored measures that require a “yes” or “no” CMS awards full points for measures submitted with a “yes.” All required measures must be reported, therefore organizations must attest “yes” or report at least one patient in the numerator, as applicable, or claim an exclusion, or they will earn a zero for the PI performance category.

For the Public Health and Clinical Data Exchange objective, full points will be awarded if a “yes” is submitted for the two required measures, Immunization Registry Reporting and Electronic Case Reporting. Reporting one “yes” and one exclusion will also satisfy the requirements. Reporting the level of active engagement for these measures is also required.

• If an ACO does not report at the APM entity level, the ACO’s individual and group scores would be calculated as a weighted average rolled up to the APM entity level.
• If an eligible clinician reports PI at the individual or group level under traditional MIPS or the APM Performance Pathway (APP) in addition to the ACO reporting MIPS PI at the APM entity level via the APP, that eligible clinician would receive the highest of the individual, group, or APM entity PI scores.

If exclusions are claimed, the points for those measures will be reallocated to other measures.

Measure Suppression Policy
Beginning in PY 2026, CMS adopted a measure suppression policy for the PI performance category. Under this policy, if CMS suppresses a measure for a given performance year, full credit/maximum points will be given as long as the measure is reported.

Bonus Points
Bonus points (five points) can be earned for submitting a “yes” response for one of the optional Public Health and Clinical Data Exchange measures: Public Health Registry Reporting, Clinical Data Registry Reporting, Syndromic Surveillance Reporting, or Public Health Reporting Using TEFCA.

Enforcement
If an ACO fails to meet these requirements, CMS may take remedial action before terminating for noncompliance. Remedial action could include a warning notice, corrective action plan, or special monitoring plan. CMS also emphasizes that ACOs’ participant agreements must allow the ACO to take remedial action against the ACO participant, including imposition of a corrective action plan, denial of incentive payments and termination of the participation agreement.

Public Reporting
CMS requires ACOs to publicly report the number of MIPS eligible clinicians, qualifying Advanced APM Participants (QPs), and Partial QPs participating in the ACO that earn a MIPS PI performance category score. For PY 2025 and subsequent years, the ACO must publicly report:

• The total number of ACO participants, providers/suppliers and professionals that are MIPS eligible clinicians, QPs, or Partial QPs that earn a MIPS performance category score for PI,
• The number of ACO participants, providers/suppliers and professionals that meet the requirements and are not excluded for the applicable performance year, and
• The total number of ACO participants, providers/suppliers, and professionals that are excluded and that voluntarily reported and received a MIPS PI score for the applicable performance year.

NAACOS Advocacy
NAACOS will continue to advocate for the removal of this new burdensome requirement. We encourage ACOs to share feedback with CMS regarding the hardship this will cause your ACO and the impact to the participation of small practices in your ACO. You can also share your feedback with NAACOS to help inform our ongoing advocacy on this issue by emailing [email protected].

Frequently Asked Questions (FAQs) on Promoting Interoperability (PI) Requirements for MSSP ACOs
NAACOS met with CMS to discuss ACOs’ unanswered questions on the requirement for MSSP ACOs to report PI and received responses to several questions. The agency also stated that there is work underway to implement processes for ACOs to report PI at the APM entity-level and to submit hardship exemption applications on behalf of participating practices. CMS will release information and guidance on these processes soon. Stay tuned! Below are the questions that were clarified by CMS during the call:

1. What is the best way to validate if a CEHRT product meets the 2015 base CEHRT definition?
   • Use the Certified Health IT Product Lookup (CHPL) tool online (https://chpl.healthit.gov/#/search) to check if the specific EHR product version indicates “100% base criteria met” for the relevant performance year.
   • Practices should look for products with an active certification status (green check mark) indicating 100% base criteria met.
2. What will ACOs need to publicly report and in what manner to satisfy the public reporting aspect of the requirements?
   • ACOs must publicly report the number of participants that reported PI (or were reported on by the ACO) and the number of participants that met requirements without exclusions for the performance year.
   • ACOs must also report the number of excluded participants who voluntarily reported PI.
   • CMS is developing guidance on how ACOs can obtain this information if they do not report at the APM entity-level. Detailed public reporting guidance will be released soon. The public reporting timeline has shifted and ACOs will not need to update this information in public reporting until late 2026 at the earliest.
3. What changes to PI have been made between PY 2024 and PY 2025?
   • No changes have been made to the way PI is scored.
   • CMS discontinued automatic reweighting for clinical social workers—now automatic reweighting only applies to ambulatory surgical centers, hospital-based, non-patient facing, and small practices.
   • CMS updated minimum criteria for PI data submission and scoring policy for multiple submissions, such that CMS will assign the highest of scores when there are multiple data submissions.
   • CMS finalized suppressing electronic case reporting (ECR) requirement from scoring for PY 2025 due to CDC pausing new organization onboarding.
4. What changes to PI have been made between PY 2025 and PY 2026?
   • CMS added a second attestation component to the Security Risk Analysis measure that requires attestation to having conducted security risk management as required under the risk management component of the HIPAA Security Rule.
   • CMS now requires the use of the 2025 SAFER Guides, updated from the 2016 version.
   • CMS added a new optional bonus measure on Public Health Reporting Using TEFCA.
   • Adopted a policy to allow CMS to suppress a measure if needed. The measure will still need to be reported and maximum credit or full credit will be received.
5. To whom does the MSSP PI requirement apply? Does it only include clinicians that are included on the ACO’s certified ACO Participant List for the relevant performance year?
   • ACOs should use snapshot 3 (released in December and covers January 1 – August 31 of the relevant performance year) on the QPP site to determine which providers/suppliers are subject to the MSSP PI requirement.
   • This includes any changes made to the provider/supplier list during the performance year through the QPP snapshot 3 window.
6. How do the exemptions that apply to individual clinicians and practices impact an ACO’s reporting? For example, are ACOs that are exclusively comprised of federally qualified health centers (FQHCs) exempt from reporting PI and what reporting, if any, is needed?
   • FQHCs and rural health clinics (RHCs) are generally not MIPS eligible, and these providers don’t need to report PI if billing exclusively under an FQHC/RHC.
   • ACOs comprised entirely of FQHCs are exempt from PI reporting and the associated public reporting requirements.
   • ACOs should verify the MIPS eligibility of their participants at the individual clinician level through the QPP lookup. (NOTE: CMS is working to clarify whether ACOs must check at the CCN level vs. NPI level for FQHC/RHC participants).
7. Do the qualifying exclusions and exemptions apply at the individual provider/practice level or at the ACO level (e.g., would the entire ACO need to be designated as a small practice to receive automatic reweighting, or could individual practices qualify and be excluded from the ACO PI requirement?)
   • Exclusions and exemptions apply at the individual provider/practice level, not at the entire ACO level (despite the fact that some ACOs have received incorrect information from the QPP help desk stating the entire ACO would need to qualify for the exclusion/exemption).
     • E.g., for an ACO with 80 total TINs, 20 of which do not exceed the low volume threshold, the ACO would only need to report PI for the 60 TINs that exceed the low volume threshold.
   • ACOs should check MIPS eligibility at the individual clinician level using the QPP website to determine which practices in the ACO are subject to the PI reporting requirement. 
8. What is the MIPS PI hardship exemption process for qualifying APM Participants (QPs) who have historically not needed to apply for MIPS reweighting?
   • CMS is working to establish processes for QPs and partial QPs to apply for the MIPS PI hardship exemption since they cannot currently apply through MIPS and plans to release detailed guidance soon.
   • CMS is also working on allowing APM entities to submit hardship exemption applications on behalf of clinicians and/or practices within the ACO.
9. How can an ACO report PI at the APM entity-level when its participants have exclusions and/or exemptions?
   • CMS is still working on detailed guidance for APM entity-level reporting that was promised in January 2025. CMS is prioritizing releasing this guidance as soon as possible but cannot provide a specific timeline.
   • This guidance will include a decision tree to help ACOs determine the reporting requirements and the best approach to satisfy them.
10. What does the CMS announcement about enforcement discretion for PY 2025 PI reporting mean for my ACO?
    • If your ACO participates in an Advanced APM track of MSSP (Basic Track Level E or Enhanced Track), this decision means your ACO and its participants are not required to report PI for PY 2025.
    • If your ACO participates in a MIPS APM track of MSSP (Basic Track Levels A-D), this decision means that your ACO (at the APM entity-level) is not required to report PI or include the ACO’s PI score in its public reporting for PY 2025. However, the decision does not impact MIPS reporting obligations for the MIPS eligible clinicians participating in your ACO. These providers are still required to report PI at the individual and/or group level, and the PI score will contribute to the final MIPS score and corresponding MIPS payment adjustment. If MIPS eligible clinicians without a documented exception/exclusion fail to report PI, it could result in a negative MIPS payment adjustment. Use the QPP portal to look up MIPS eligibility status and available exceptions/exclusions.
    • If your ACO participates in either track of the ACO REACH Model, this decision does not affect your ACO. REACH ACOs are required to attest annually to participants’ use of CEHRT. Refer to the ACO REACH Participation Agreement for details.
11. Following the CMS announcement to not enforce the MSSP PI requirement for PY 2025, can my ACO still choose to report PI to prepare for PY 2026?
    • Yes, MSSP ACOs still have the option to choose to report PI for PY 2025. However, CMS notes that reporting PI will result in a MIPS score and payment adjustment to the ACO’s MIPS eligible clinicians. That means that even if you are participating in an Advanced APM track of MSSP, reporting PI could result in a MIPS score and payment adjustment for clinicians in the ACO who are not QPs or partial QPs for the relevant performance year. Use the QPP portal to check your participants’ status and determine whether reporting PI could trigger a MIPS score and payment adjustment.
    • Clinicians with QP status aren’t eligible for a MIPS payment adjustment, regardless of what data are submitted. Partial QPs are only eligible for a MIPS payment adjustment if the ACO makes a Partial QP election.
12. Does this CMS announcement mean that the PI requirements for MSSP ACOs are going away?
    • No. This announcement effectively delays implementation of the PI requirements for MSSP ACOs until PY 2026 and ACOs should still plan to comply with the requirements moving forward. NAACOS will continue to advocate for CMS to repeal these requirements and identify less burdensome ways to assess ACO participants’ CEHRT use, such as through the use of an attestation.

Additional information is available in the APM Performance Pathway (APP) toolkit scoring guide (download the toolkit from the QPP Resource Library)

Appendix
A detailed summary of PI requirements is outlined in the final 2026 Medicare Physician Fee Schedule rule in Table C-G2, Objectives and Measures for the Promoting Interoperability Performance Category for the 2026 Performance Period. Table C-G3 outlines the scoring methodology for the 2026 Performance Period.