2021 NACOR Order Form

2021 NATIONAL ANESTHESIA CLINICAL OUTCOMES REGISTRY (NACOR) Order Form
Select the desired 2021 NACOR service

NACOR Quality Reporting NACOR Benchmarking NACOR Basic
NACOR Quality Reporting Form
(Group Practice Reporting QR/QCDR or Individual QR/QCDR)

This form is only for:
- NACOR-Group Practice Reporting Qualified Registry (QR)
- NACOR-Group Practice Reporting Qualified Clinical Data Registry (QCDR)
- NACOR-Individual Qualified Registry (QR)
- NACOR-Individual Qualified Clinical Data Registry (QCDR)
If you are ordering NACOR Basic or NACOR Benchmarking, please change selection above.

If you are a Quality Concierge customer, please do not fill out this order form. If you have questions, contact qcdr@asahq.org.
Email
example@example.com
NACOR Benchmarking Form
(National benchmarking; measure compliance and quality improvement initiatives)

This form is only for NACOR Benchmarking

If you are ordering NACOR Quality Reporting or NACOR Basic, please change selection above.

If you are a Quality Concierge customer, please do not fill out this order form. If you have questions, contact qcdr@asahq.org.
INSTRUCTIONS FOR NACOR QUALITY REPORTING
- Review NACOR fees 2021 NACOR Pricing based on each provider's ASA membership status. Please note that for 2021, ASA members will incur a nominal fee for NACOR Quality Reporting.
- Select your reporting option.
  Indicate whether your practice is a new NACOR customer (did not participate last year)or a renewal (participated last year).
- If your practice is an existing NACOR customer, please provide your AQI Practice ID. Contact AQI if you do not know your Practice ID.
- Indicate whether this is a new order, replacing an existing order, or adding providers to an existing order.
- Enter provider quantities according to provider type and ASA member status. Please be as accurate as possible.
- Enter contact, practice and billing information.
- Click "Submit Order" at the bottom of the form.
- You will receive an email confirmation shortly.
Questions? askaqi@asahq.org

PAYMENT POLICIES AND PROCEDURES
- Agreements : In order for your practice to participate in NACOR Quality Reporting, a NACOR Participation Agreement and a Quality Reporting Addendum are required. If your practice did not previously participate in NACOR Quality Reporting, the required contracts and invoice will be emailed to you once your order is processed.
- Initial Payment : Your practice will receive an invoice after the order has been processed for the number of eligible clinicians that you reported on your order form (NOTE: your number of reported eligible clinicians should reflect the number of providers intending to submit data to AQI for the selected service as of the order date). Terms of payment are net 30 days. No data will be accepted by AQI until payment is received.
- Login information for new participating groups : will be emailed to the practice champion (designated in the NACOR Participation Agreement) once fees are paid.
- Final Payment : Beginning in January 2022, ASA will reconcile the number of eligible clinicians paid for in your Initial Payment against actual data submitted by the practice and generate a final reconciliation invoice for any additional providers, if applicable. All payments must be received by March 15, 2022. Refunds will not be issued. Example: If a practice ordered NACOR Quality Reporting services for 10 CRNAs but submitted data for 12 CRNAs, ASA will invoice for the 2 additional CRNAs. If ASA does not receive payment for the 2 additional CRNAs by March 15, 2022, at AQI’s discretion the additional CRNAs’ data may not be submitted to CMS.
- 2021 Membership: Payment is determined by 2021 ASA membership status. Please note the following NEW deadlines:
October 1 - NACOR registration deadline (Please note: non-members would have to pay the non-member pricing)
October 1 - deadline to become an ASA member for 2021; practices must supply list of non-members becoming members to ASA membership
October 25 -last day to pay ASA dues for 2021 membership
- Locum Tenens : Data submitted for all providers, including locums, temporary staff or part-time staff will be included in the provider count.
- Additional Information for Group vs. Individual Reporting : Group Reporting: All Eligible Clinicians (ECs) in your group billing must be included in the data submitted to NACOR. Individual Reporting: CMS requires every Eligible Clinician (EC) submit a consent form for individual reporting practices. Each EC for which you intend to submit quality data must sign a consent form for 2021. CMS requires this consent be collected annually. Your practice is to keep a copy of the consents in your files for a period of seven years, in case of CMS audit. You will receive a copy of the consent form with your signed agreements or you can locate it on the AQI website. AQI Website
The Opt-In option is only available to practices which do not meet all three of the 2021 MIPS eligibility criteria (bill more than $90,000 for Part B covered services, see more than 200 Part B patients and provide 200 or more covered professional services to Part B patients).
- Please check your clinician's 2021 MIPS eligibility to see if you your practice meets the criteria to opt in. If your practice is not MIPS eligible but meets one or two of the MIPS criteria and would like to submit 2021 MIPS data for a potential payment adjustment, please select the Opt-In box.
- If you choose to Opt-In , email askaqi@asahq.org askaqi@asahq.org to provide the NPIs for those clinicians who will be included.
- Administrative costs : NACOR administrative costs are incurred during the data reporting year for each clinician, MD, CRNA, etc., in the data files that are processed; the final invoice will be based on this head count. Final payment of invoices is required even if data is not submitted to CMS as this is a NACOR administrative fee, not a CMS fee. Participants may not be allowed to register for future reporting until all outstanding invoices are paid.
Questions?: Email askaqi@asahq.org
NACOR Basic Form
(Comprehensive benchmarking for internal quality improvement)

This form is only for NACOR Basic

If you are ordering NACOR Quality Reporting or NACOR Benchmarking, please change selection above.

If you are a Quality Concierge customer, please do not fill out this order form. If you have questions, contact qcdr@asahq.org.

INSTRUCTIONS FOR NACOR BENCHMARKING
- Review NACOR fees 2021 NACOR Pricing based on each provider's ASA membership status. Please note that for 2021, ASA members will incur a nominal fee for NACOR Quality Reporting.
- Indicate whether your practice is a new NACOR customer (did not participate last year)or a renewal (participated last year).
- If your practice is an existing NACOR customer, please provide your AQI Practice ID. Contact AQI if you do not know your Practice ID.
- Indicate whether this is a new order, replacing an existing order, or adding providers to an existing order.
- Enter provider quantities according to provider type and ASA member status. Please be as accurate as possible.
- Enter contact, practice and billing information.
- Click "Submit Order" at the bottom of the form.
- You will receive an email confirmation shortly..
Questions? Email askaqi@asahq.org

PAYMENT POLICIES AND PROCEDURES
- Agreements: In order for your practice to participate in NACOR Benchmarking, a NACOR Participation Agreement is required. If your practice did not previously participate in NACOR Benchmarking, the required contract and invoice will be emailed to you once your order is processed.
- Initial Payment: Your practice will receive an invoice after the order has been processed for the number of eligible clinicians that you reported on your order form. Terms of payment are net 30 days. No data will be accepted by AQI until payment is received.
- Login information: For new participating groups, login details will be emailed to the practice champion (designated in the NACOR Participation Agreement) once fees are paid.
- Final Payment: Beginning in January 2022, ASA will reconcile the number of eligible clinicians paid for in your Initial Payment against actual data submitted by the practice and generate a final reconciliation invoice for any additional providers, if applicable. All payments must be received by March 15, 2022. Refunds will not be issued. Example: If a practice ordered NACOR Quality Reporting services for 10 CRNAs but submitted data for 12 CRNAs, ASA will invoice for the 2 additional CRNAs.
- 2021 Membership: Final Payment is determined by 2021 ASA membership status. Please note the following NEW deadlines:
  
  October 1 - NACOR registration deadline (Please note: non-members would have to pay the non-member pricing)
  
  October 1 - deadline to become an ASA member for 2021; practices must supply list of non-members becoming members to ASA membership
October 25 - last day to pay ASA dues for 2021 membership
- L ocum Tenens : Data submitted for all providers, including locums, temporary staff or part-time staff will be included in the provider count.
- Administrative costs : NACOR administrative costs are incurred during the data reporting year for each clinician, MD, CRNA, etc., in the data files that are processed; the final invoice will be based on this head count. Final payment of invoices is required. Participants may not be allowed to register for future reporting until all outstanding invoices are paid.
Questions? Email askaqi@asahq.org
Indicate whether your practice is a new NACOR customer or a renewal *

New Renewal
INSTRUCTIONS FOR NACOR BASIC
- Review NACOR fees 2021 NACOR Pricing based on each provider's ASA membership status.
- Indicate whether your practice is a new NACOR customer (did not participate last year) or a renewal (participated last year).
- If your practice is an existing NACOR customer, please provide your AQI Practice ID. Contact AQI if you do not know your Practice ID.
- Indicate whether this is a new order, replacing an existing order, or adding providers to an existing order.
- Enter provider quantities according to provider type and ASA member status. Please be as accurate as possible.
- Enter contact, practice and billing information.
- Click "Submit Order" at the bottom of the form.
- You will receive an email confirmation shortly.
Questions? Email askaqi@asahq.org

PAYMENT POLICIES AND PROCEDURES
- Agreements: In order for your practice to participate in NACOR Basic, a NACOR Participation Agreement is required. If your practice did not previously participate in NACOR Benchmarking, the required contract and invoice will be emailed to you once your order is processed.
- Initial Payment: Your practice will receive an invoice after the order has been processed for the number of eligible clinicians that you reported on your order form (NOTE: your number of reported eligible clinicians should reflect the number of providers intending to submit data to AQI for the selected service as of the order date). Terms of payment are net 30 days. No data will be accepted by AQI until payment is received.
- Login information: For new participating groups, login details will be emailed to the practice champion (designated in the NACOR Participation Agreement) once fees are paid.
- Final Payment: Beginning in January 2022, ASA will reconcile the number of eligible clinicians paid for in your Initial Payment against actual data submitted by the practice and generate a final reconciliation invoice, if applicable. All payments must be received by March 15, 2022. Refunds will not be issued. Example: If a practice ordered NACOR Basic services for 10 ASA Member Anesthesiologists, but submitted data for 12 Member Anesthesiologists, ASA will invoice for 2 additional Member Anesthesiologists.
- 2021 Membership: Final Payment is determined by 2021 ASA membership status. Please note the following NEW deadlines:
  
  October 1 - NACOR registration deadline (Please note: non-members would have to pay the non-member pricing)
  
  October 1 - deadline to become an ASA member for 2021; practices must supply list of non-members becoming members to ASA membership
  
  October 25 - last day to pay ASA dues for 2021 membership
- Locum Tenens: Data submitted for all providers, including locums, temporary staff or part-time staff will be included in the provider count.
- Administrative Costs: NACOR administrative costs are incurred during the data reporting year for each clinician, MD, CRNA, etc., in the data files that are processed; the final invoice will be based on this head count. Final payment of invoices is required. Participants may not be allowed to register for future reporting until all outstanding invoices are paid.
  Questions? Email askaqi@asahq.org

SELECT REPORTING OPTION *
AQI Practice ID
If you are unsure of your AQI Practice ID, please contact askaqi@asahq.org If your PID is less than 4 digits, please add leading zeros to your ID.
Select one of the following options: *

This is a new 2021 NACOR Order This replaces a previous 2021 NACOR Order This adds providers to an existing 2021 NACOR Order
Does your practice have any providers who will "Opt-In" for 2021reporting? *

Yes, we have eligible clinicians who will "Opt-In" for 2021 No, we do not have any eligible clinicians who will "Opt-In" for 2021 MIPS reporting
If yes, email askaqi@asahq.org or contact your AQI Account Manager to provide the NPIs for these clinicians who will "Opt-In".

ASA MEMBER Physician Anesthesiologist Price
NON-MEMBER Physician Anesthesiologist Price
ASA MEMBER Care Team Clinician Price
Care team = Medically supervised and directed by physician anesthesiologist (Excludes Residents)
NON-MEMBER Care Team Clinician Price
Care team = Medically supervised and directed by physician anesthesiologist (Excludes Residents)
ASA MEMBER Independent Nurse Anesthetist Price
Independent practice WITHOUT physician anesthesiologist medical supervision and direction
NON-MEMBER Independent Nurse Anesthetists Price
Independent practice WITHOUT physician anesthesiologist medical supervision and direction

{selectThe} Order Form

Provider Type	Price
ASA MEMBER Physician Anesthesiologists	${asa-pa}
NON-MEMBER Physician Anesthesiologists	${non-pa}
ASA MEMBER Care Team Clinicians Supervised by physician anesthesiologist (Excludes Residents)	${asa-ctc}
NON-MEMBER Care Team Clinicians Supervised by physician anesthesiologist (Excludes Residents)	${non-ctc}
ASA MEMBER Independent Nurse Anesthetists Independent practice without physician anesthesiologist supervision (NOTE: Complete this section only for Independent Nurse Anesthetists who are current, active ASA educational members.)	${asa-ina}
NON-MEMBER Independent Nurse Anesthetists Independent practice without physician anesthesiologist supervision	${non-ina}

NACOR benefits are included with ASA Member Dues for NACOR Basic only.

ASDA Members With ASA Educational Membership: Select the “ASA Member Physician Anesthesiologists” category. Non-ASA Members should select the “Non-Member Anesthesiologists” category.

Indicate the provider quantities above for each ASA Current Member and ASA Non-Member participating in 2021 reporting.

Provider Quantities (Enter At LEAST one category)

ASA MEMBER Physician Anesthesiologists *
NON-MEMBER Physician Anesthesiologists *
ASA MEMBER Care Team Clinicians *
No Residents
NON-MEMBER Care Team Clinicians *
No Residents
ASA MEMBER Independent Nurse Anesthetists *
NON-MEMBER Independent Nurse Anesthetists *
Total Number of Providers
Total Amount
Calculated Total Amount
Calculated Total Quantity

Name of person placing order *

First Name Last Name
E-mail address of person placing order *

Confirmation Email
Contact number of person placing order *

Practice Name *
Please provide complete Practice Name
Street Address *
City *
State *
Zip Code *
Tax Identification Number (TIN)

AQI will need all the Tax ID's for which your organization bills Medicare Part B claims. Most groups use a single Tax ID for this; however if your organization bills separately for your anesthesiologists vs. your CRNA's, or if your organization bills using a different Tax ID for each of the facilities where services are provided, you will need to provide all Tax ID's applicable.
Tax Identification Number (TIN) 1 - Numbers only; no dashes. *
A nine-digit number that the IRS assigns to organizations.
Tax Identification Number (TIN) 2 - Numbers only; no dashes.
A nine-digit number that the IRS assigns to organizations.
Tax Identification Number (TIN) 3 - Numbers only; no dashes.
A nine-digit number that the IRS assigns to organizations.

Billing Contact Name *

First Name Last Name
Billing Contact Email *
Billing Address *
City *
State *
Zip Code *

I have read the instructions and acknowledge receipt of the payment polices and procedures *

Check confirmation

{selectThe} Order Preview

{selectReporting}

New, Replace or Append Order: {NewUpdateOrReplaceOrder}

Name: {ContactName} Email: {ContactEmail} Phone: {ContactPhone}

Practice	TIN
{PracticeName}	{taxIdentification1}
{PracticeStreetAddress}	{taxIdentification2}
{PracticeCity}, {PracticeState}, {PracticeZipCode}	{taxIdentification3}

Billing Contact	Email
{BillingContactEmail}	{BillingContactEmail}
{BillingAddress}
{BillingCity}, {BillingState}, {BillingZipCode}

Provider Type	Price	Qty
ASA MEMBER Physician Anesthesiologists	${asa-pa}	{ASAMemPA}
NON-MEMBER Physician Anesthesiologists	${non-pa}	{NonMemPA}
ASA MEMBER Care Team Clinicians (Exludes Residents)	${asa-ctc}	{ASAMemCTC}
NON-MEMBER Care Team Clinicians (Exludes Residents)	${non-ctc}	{NonMemCTC}
ASA MEMBER Independent Nurse Anesthetists	${asa-ina}	{ASAMemINA}
NON-MEMBER Independent Nurse Anesthetists	${non-ina}	{NonMemINA}
Total	${TotalAmount}	{TotalProviders}

Please enter your initials to confirm that you are purchasing the above ASA/AQI product. *
Payment is due within 30 days of receiving invoice.
Should be Empty:

2021 NATIONAL ANESTHESIA CLINICAL OUTCOMES REGISTRY (NACOR) Order Form

{selectThe} Order Form

Provider Type

Price

Provider Type

Price

Qty