Measure Submission to the CMS CBE

The consensus-based endorsement process enables endorsement decision-making in as few as 6 months. This 6-month process occurs during either a fall or spring measure endorsement cycle, depending on when the measure steward/developer submits a measure for endorsement consideration (see figure). Under this process, the endorsement project committees review candidate measures against the CBE evaluation criteria to render an endorsement decision.

The CMS CBE 6-month endorsement review process

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Measure Submission Timeline

For each measure evaluation cycle (i.e., fall or spring), the measure steward/developer must submit an Intent to Submit (ITS) followed by Full Measure Submission (FMS) by the designated deadlines (see table). The CMS CBE requires the measure steward/developer to submit an ITS followed by an FMS for each measure they desire endorsement consideration.

ITS and FMS Deadlines by Cycle

E&M Cycle	Intent to Submit*	Full Measure Submission*
Fall	October 1	November 1
Spring	April 1	May 1

*The CMS CBE has set deadlines at 11:59 p.m. (ET) of the day indicated. If the deadline ends on a weekend or holiday, the deadline will be the next business day.

Submit the ITS to the CME CBE

Prior to submitting a measure, the measure steward/developer must first create an account by going to the “Submit a Measure” page on the PQM website. When initiating an online measure submission, the measure steward/developer may contact the CMS CBE for assistance.

The CMS CBE requires measure stewards/developers to submit an ITS through its Submission Tool and Repository (STAR) at least 1 month prior to the FMS deadline for the intended review cycle. STAR is an online platform where measure stewards/developers can submit measures and any interested party may search and view measure information, including the endorsement status. The database is updated regularly as measure stewards/developers submit new and maintenance measures to the CMS CBE for endorsement review.

The ITS submission notifies the CMS CBE of the measure steward’s/developer’s readiness to submit a measure for endorsement consideration and allows opportunity for technical assistance before submission. See an example of the information needed to submit the ITS.  

If the measure steward/developer is submitting to the CBE for the first time when submitting the ITS, the measure steward/developer must complete the Quality Measure Developer and Steward Agreement (QMDSA). All measures not owned by a government entity require a measure steward. QMDSAs are effective for 5 years. Please review the QMDSA Submission Instructions for more information. 

If a measure steward/developer is submitting a measure for maintenance or wants to add measures to an existing QMDSA, the measure steward must complete the Additional and Maintenance Measures Form.

Complete the CMS CBE Measure Submission

After completing ITS submission, the measure steward/developer will submit the full measure information (e.g., evidence, testing) by the respective deadline for the cycle. The CMS CBE uses STAR to provide easier submission of measure information. The CMS CBE provides a template, which provides an example of the information required and enables the measure steward/developer to 

• assign a specific section for completion to a particular subject matter expert 
• save a draft version of the measure submission and return to complete it at their convenience
• print a copy of the measure submission for reference or other uses, if desired

The measure steward/developer is responsible for completing the FMS and ensuring the information is sufficient to meet the CMS CBE’s requirements. The measure submission is the measure steward’s/developer’s presentation of the measure to the project committee and interested parties to demonstrate the measure meets the criteria for endorsement. 

Tips for Successful CMS CBE Submission

• Contact the CMS CBE project staff for technical assistance with the submission and evaluation process.
• Answer every part of the CMS CBE measure submission clearly, concisely, and ensure readers, including the patient community, may comprehend as a standalone document.
• Provide substantive, practical responses to each item.
• Include specific page numbers, table numbers, links, etc. in supplementary materials (e.g., attachments, references, and Uniform Resource Locators [URLs]).
• Ensure all materials are 508-compliant.
• Submit attachments or URLs, as needed, for long lists of codes or other data elements used in the measure, details of a risk adjustment model, and the calculation algorithm.
• Provide supportive evidence the patient community finds the measure meaningful/valuable.
• If conducting entity-level validity testing, describe the hypothesis and provide a rationale for why the measure did or did not reach the hypothesis.
• Provide any pilot test data available, even if the data do not satisfy the CMS CBE’s entire testing requirements.
• Document the rationale for all decisions in the specifications.
• Document the rationale for all denominator and numerator exclusions.
• Discuss any controversies about the science behind the measure and why the measure steward/developer specified the measure as it did.
• If measure is not in use or has feasibility challenges, provide a near-term path for its use and implementation guidance to overcome any feasibility concerns.

For questions about the online submission, contact PQMSupport@battelle.org. 

Measure Harmonization

The measure steward/developer should search for related and competing measures early during the information gathering phase of development and again just prior to submission to the CMS CBE. A measure steward/developer may not discover existing measures for the same condition, process of care, outcome, or care setting until after the submission of measures to the CMS CBE. If that happens, the CMS CBE project committee reviewing the measure could request both measure stewards/developers create a harmonization plan addressing the possibility and challenges of harmonizing their respective measures.