The CMS CBE Endorsement Process
The CMS CBE follows a consensus-based process. Please view the E&M Guidebook for more information on this process and for updates to timelines and approaches. Measure stewards/developers should also monitor the PQM E&M webpage for new information.
Measure Steward's/Developer's Role During the CMS CBE Evaluation
During the CMS CBE evaluation, measure stewards/developers
- Provide a factual review of the CMS CBE's preliminary measure assessment.
- Review public and committee comments on the measure submission.
- Attend project committee meetings to:
- Provide context, rationale, and other insights about the measure.
- Answer questions posed by committee members.
During its evaluation, the CMS CBE may suggest changes to the measure to make it more acceptable, to harmonize with other measures, or both.
Endorsement Decision Outcomes
Measures submitted for endorsement review receive one of the following endorsement decisions listed in the table below.
| Decision Outcome | Description | Maintenance Expectations |
|---|---|---|
| Endorsed | Applies to new and maintenance measures. The E&M committee agrees by 75% or more to endorse the measure. | Measures undergo maintenance of endorsement reviews every 5 years with a status report review at 3 years. Developers/stewards may request an extension of up to 1 year (two consecutive cycles), unless it has been more than 6 years since the measure’s date of last endorsement. |
| Endorsed with Conditions* | Applies to new and maintenance measures. The E&M committee agrees by 75% or greater that the measure can be endorsed as it meets the criteria, but committee reviewers have conditions they would like to be addressed when the measure comes back for maintenance. If these recommendations are not addressed, the developer/steward should provide a rationale for consideration by the E&M committee. | Measures undergo maintenance of endorsement reviews every 5 years with a status report review at 3 years, unless the condition requires the measure to be reviewed earlier. The E&M committee evaluates whether conditions have been met, in addition to all other maintenance endorsement minimum requirements. |
| Not Endorsed° | Applies to new measures only. The E&M committee agrees by 75% or greater to not endorse the measure. | None. |
| Endorsement Removed° | Applies to maintenance measures only. Either:
| None. |
*Conditions are recommended by the E&M committee, with the consideration of what is feasible and appropriate for the developer/steward to execute by the time of maintenance endorsement review.
°Measures that fail to reach the 75% consensus threshold are not endorsed.
The “Endorsed with Conditions” category serves as a means of endorsing a measure but with conditions recommended by the committee. These conditions are actions/activities that the developer/steward should undertake prior to the next maintenance cycle. When considering a condition, the E&M committee assesses what is feasible and appropriate for the measure developer/steward to execute by the time of maintenance endorsement review. If a measure with an “Endorsed with Conditions” designation is evaluated for maintenance but it has not met the prior conditions, then the committee may choose to remove endorsement, unless it agrees with any rationale provided by the developer/steward. Learn more in the E&M Guidebook found on the PQM E&M webpage.
Measure Maintenance for Endorsement
Once a measure is endorsed, it will enter a 5-year maintenance cycle, at which time the measure is resubmitted to the CBE for endorsement review. Prior to the 5-year maintenance review, there are several opportunities for measure developers/stewards to report changes to the measure specification:
- Annual Updates: Measure developers/stewards have the option to submit an annual update of the measure specifications to the CMS CBE. This report either reaffirms that the measure specifications remain the same as those at the time of endorsement or last update or outline any changes or updates made to the endorsed measure, including the purpose for the changes.
- Three-Year Status Update: At 3 years since the measure’s endorsement, developers/stewards provide a status report indicating whether any changes to the measure specifications are needed. The developer/steward may also attest if no changes are required. Once the 3-year status report is submitted, the CMS CBE will review to confirm if any indicated changes require the measure to be submitted for endorsement review before the 5-year maintenance cycle.
- Ad Hoc Status Update: If changes occur to a measure at any time in between the measure’s last endorsement review and its scheduled maintenance endorsement review, the measure steward is responsible for informing the CMS CBE immediately by submitting a status report. An early maintenance review is conducted if the changes materially affect the measure’s original concept or logic (see Emergency/Off-Cycle Review section of the E&M Guidebook for more information).