This month's reminders from the AzFlex Team
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April 2017

MBQIP Data Submission Reminders

Emergency Department Transfer Communication (EDTC) Measures | Due: Saturday, April 15, 2017

CMS Outpatient Measures

Attention: As most of you are aware, there have been issues with the submission of Outpatient Population and Sampling data through the grid in the QualityNet Secure Portal. Population and Sampling is not required, however, it is encouraged for you to use. Population and Sampling shows the difference between reporting 0 eligible cases, cases that were submitted but excluded vs. not reporting at all. 

The FORHP continues to work with CMS regarding the issues with entry of outpatient population and sampling data via the QualityNet Secure portal. Until the population and sampling issue for CAHs is resolved an XML programming work-around has been created for you to use.

To support submission through the work-around XML process, the Outpatient Reporting Support Center hosted a webinar training yesterday. If you were unable to attend, go to for the recorded presentation and XML template.

For technical questions on the XML file format or submission, please contact the QualityNet Help Desk by phone at (866)800-8756 or via e-mail at

CMS Population and Sampling (optional)* | Due: May 1, 2017 

  • Patients seen Q4 2016 (October, November, December)
  • Outpatient and Inpatient measures
  • Entered via Secure Portal on QualityNet 
*Population and sampling refers to the recording of the number of cases the hospital is submitting to the QualityNet warehouse, this is done directly thru the QualityNet Secure Portal. Reporting of population and sampling data is strongly encouraged but not required in order for your data to be submitted to CMS


CMS Outpatient Measures: OP-1 - OP-5, OP-18, OP-20, OP-21  | Due: Monday, May 1, 2017

  • Patients seen Q4 2016 (October, November, December)
  • CART version 1.15
  • CMS Hospital Outpatient Reporting Specifications Manual version  9.1
  • Submitted to the QualityNet warehouse via CART or by vendor

CMS Outpatient Web-based Measures: OP-22 | Due May 15, 2017

  • OP-22: Patient Left Without Being Seen -Full calendar year January-December 2016
  • CMS Hospital Outpatient Reporting Specifications Manual version  9.1
  • Entered via the Secure Portal on QualityNet

CMS Inpatient Measures: IMM-2 Influenza Immunization, ED-1 & ED-2 | Due: MondayMay 15, 2017

  • Patients seen Q4 2016 (October, November, December)
  • CART version 4.19.1
  • CMS Hospital Inpatient Reporting Specifications Manual version 5.1
  • Submitted to the QualityNet warehouse via CART or by vendor

Healthcare Personnel Influenza Vaccination: OP-27 | Due, Monday, May 15, 2017

  • Percentage of personnel vaccinated
  • Time frame: October 1, 2016 - March 31, 2017
  • Submitted through the National Healthcare Safety Network (NHSN)

MBQIP Updates/Reminders

AzCAH Quality Network Webinar | Tuesday, April 18, 2017 | 2:00 pm
Click here to register

CART Tips:
  1. Submit by deadline. QualityNet warehouse does not accept data after the deadlines noted above.
  2. After your data is submitted to the QualityNet warehouse you will get confirmation that data was received.
  3. To see if your data was accepted or rejected run a Case Status Summary (For more information on running Case Status Summary Reports,go to page 7 in the MBQIP Quality Improvement Guide, section 6,  Check Submitted Cases).
  4. If data was rejected, run the Submission Detail Report to show why the case was rejected.. You can still make changes to your data until the deadline.
MBQIP Monthly March 2017: 
MBQIP Monthly is an e-newsletter that highlights current information about the Medicare Beneficiary Quality Improvement Project (MBQIP), and provides critical access hospitals (CAHs) with information and support for quality reporting and improvement. In this issue:
  • CAHs Can! Rural Success: Avera DeSmet Memorial Hospital, South Dakota
  • Data: CAHs Measure Up – Finding and Using Benchmarking Data
  • Tips: Robyn Quips – Communications from the Centers for Medicare and Medicaid (CMS)
  • Tools and Resources: Helping CAHs Succeed in Quality Reporting & Improvement
New to Quality Reporting?
Visit the AzFlex webisite for MBQIP Resources

The National Rural Health Resource Center MBQIP Resource Library also provides resources to get started. click here for more information.

AzFlex Team

Jill Bullock | Associate Director | Flex Coordinator |
Joyce Hospodar | Senior Advisor, Rural Programs |
Bryna Koch | Special Projects Coordinator |

Copyright © 2017*The University of Arizona Center for Rural Health, All rights reserved.

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1295 N. Martin Ave. PO Box 245210
Tucson, AZ 85724

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The University of Arizona Center for Rural Health · 1295 N. Martin Ave. · P.O. Box 245163 · Tucson, AZ 85724 · USA

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