Claimocity Claims
How Providers Know If They
Need to Participate in MIPS
What Is MIPS?
Between patient rounds, documentation, and billing, it’s hard to keep track of one more acronym. Still, MIPS affects how you’re paid, so it should get a little more attention. Maybe you still don’t really understand it. Maybe you’re wondering if it applies to you. Maybe you’re not sure what happens if you ignore it, or maybe you just want a straight answer about whether you need to participate.
MIPS participation isn’t required for everyone. Whether you’re required to report depends on specific numbers that CMS evaluates each year. Most providers just want to know what applies to them and what doesn’t. Understanding your eligibility lets you spend time on what actually matters and stop worrying about the rest.
In this guide, we’ll walk you through what determines MIPS eligibility, what the thresholds mean, and how to verify your status.
MIPS (Merit-Based Incentive Payment System) is Medicare’s way of deciding if you get a bonus, a penalty, or your pay stays the same. It ties your performance metrics to your medicare reimbursements, meaning high-performing clinicians can earn higher reimbursements, while those who fall short may see a reduction. The goal is to reward better care, not just more of it.
If you participate in MIPS, CMS evaluates your performance across four categories: Quality, Cost, Improvement Activities, and Promoting Interoperability. Your performance generates a score, and that score determines whether you receive a payment adjustment: positive, negative, or neutral.
For providers who meet certain volume thresholds with Medicare patients, MIPS participation is mandatory. For others, it’s optional or not applicable at all.
MIPS Eligibility Criteria: Who Needs to Participate?
The MIPS Eligibility Determination Period
Here’s the deal: CMS looks at three numbers to decide if you’re in or out of MIPS. Meeting all three requires you to report; meeting one or two makes you eligible to opt in.
The Three Thresholds:
- $90,000 or more in Medicare Part B allowed charges
- 200 or more Medicare Part B patients
- 200 or more covered professional services under Medicare Part B
Required to Report: If you exceed all three thresholds, you must participate in MIPS. Your performance score will determine whether you receive a positive, neutral, or negative adjustment to your Medicare payments.
Opt-In Eligible: If you meet one or two of the thresholds, you can choose to participate in MIPS voluntarily. Opting in means your performance will be scored, and your Medicare payments may be adjusted up or down based on your results. If you choose not to opt in, you’ll be excluded from MIPS for that year and won’t receive any payment adjustment.
Excluded: If you don’t meet any of the three thresholds, you do not have a reporting requirement.
These thresholds can change year to year, and CMS announces updates annually. For 2025, these are the numbers you’re working with, but always double-check the current year’s requirements on the CMS Quality Payment Program website.
What counts as a “covered professional service”?
Any billable service under the Medicare Physician Fee Schedule.
Group vs Individual Clarification:
MIPS eligibility is determined at the individual provider level using your NPI, not at the group level. This is a common misconception. Even if you’re part of a large group practice, your personal Medicare billing numbers determine whether you need to participate in MIPS.
When you check your status on qpp.cms.gov, look for a green checkmark next to your individual name. That means you’re required to report. Sometimes the checkmark only appears next to the group name, which means you’re not required to report individually.
Your MIPS status for any given year isn’t based on what you’re doing that year. CMS looks backward at your Medicare billing history to decide if you’re in or out.
They evaluate your data using two consecutive 12-month segments, a two-year look-back period. This helps create a more accurate picture of your average activity. One unusually slow or busy year won’t automatically swing your eligibility status.
What this means for you:
By the time a performance year starts, your eligibility is already decided based on old data. If you crossed a threshold during those determination periods, you’re participating, even if your current year looks completely different. Had a slow stretch during the determination window? You might be exempt for the upcoming year, regardless of how busy you are now.
Check your status early. CMS typically releases preliminary eligibility information in the fall before a performance year begins, but waiting until November is too late if you need to prepare. Check your eligibility status in February or March to give yourself adequate time to set up reporting systems and choose your quality measures if you’re required to participate.
Group Practices
MIPS eligibility is determined at the individual provider level using your NPI, not at the group level. This is a common point of confusion. Even if you’re part of a large group practice, your personal Medicare billing numbers determine whether you need to participate in MIPS.
Exclusions and Exceptions
Newly Enrolled Medicare Clinicians
If you’re in your first year of participating in Medicare, you’re excluded from MIPS participation. CMS gives new providers time to establish their practice patterns before requiring quality reporting.
Advanced Alternative Payment Model (APM) Participants
If you participate in an Advanced APM and meet its thresholds, you’re excluded from MIPS. Advanced APMs have their own quality reporting requirements.
Hospital-Based Clinicians
Clinicians who provide 75% or more of their services in inpatient hospital settings or emergency departments are excluded based on place-of-service codes.
Small Group Practices
Groups with fewer than 15 clinicians receive automatic reweighting in the Promoting Interoperability category, which affects how your final MIPS score is calculated.
Step-by-Step: How to Check Your Status
These rules can get complicated depending on your specific situation. CMS provides a lookup tool that gives you a definitive answer based on your NPI.
Here’s how to check your status:
- Go to qpp.cms.gov and navigate to the participation status tool
- Enter your NPI (National Provider Identifier)
- Review your results. The tool will show one of three statuses:
- A green check mark next to your individual name means you’re required to report
- A green check mark next to only your group name means you’re not required to report individually
- No checkmark means you’re below the thresholds or excluded
Your status can change based on your billing patterns from the determination period, so check every year even if you were exempt previously.
Understanding the Four MIPS Categories
Groups with fewer than 15 clinicians receive automatic reweighting in the Promoting Interoperability category, which affects how your final MIPS score is calculated.
Quality (30%)
Measures the effectiveness of the care you provide through specific clinical measures relevant to your specialty.
Cost (30%)
Evaluates how efficiently you deliver care compared to similar providers.
Improvement Activities (15%)
Recognizes efforts to improve clinical practice, such as care coordination, patient safety initiatives, or participation in quality improvement programs.
Small Group Practices (25%)
Assesses how well your practice uses certified EHR technology to share and manage data and improve patient care.
Your reporting requirements will vary based on your eligibility and practice type, but knowing these categories helps you track the right measures from the start.
Simplifying MIPS Compliance with Claimocity
Figuring out if you need to participate in MIPS is one thing. Actually doing it is another.
MIPS reporting means tracking specific metrics throughout the year, submitting data to CMS, and meeting deadlines. At Claimocity, we get that it’s another administrative task competing for your time, time you’d rather spend elsewhere. We’re here to make it one less thing for you to manage.
Our platform works with Patient360, a CMS-qualified registry, to handle your MIPS reporting automatically. While you document patient care in your EHR, Claimocity captures the performance data CMS needs. When it’s time to report, we send everything to Patient360, and they submit it to CMS for you.
No more worrying about deadlines or navigating complicated government portals. Whether you’re required to participate or choosing to opt in, Claimocity takes the administrative burden off your plate so you can stay compliant with MIPS requirements without the headache.
