NEW HAMPSHIRE MEDICAID EHR INCENTIVE PROGRAM. Reference Guide for Eligible Professionals

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1 NEW HAMPSHIRE MEDICAID EHR INCENTIVE PROGRAM Reference Guide for Eligible Professionals

2 REVISION HISTORY Version Number Date Comments 1.0 March 1, 2012 Initial Distribution to Pilot Participants; CMS Review 2.0 Published on Medicaid EHR Website Page 2 of 37

3 Table of Contents EHR Incentive Program... 4 Provider Outreach & Recruitment... 5 Federal Pre Registration... 6 CMS Registration & Attestation System... 7 State Pre Registration... 8 Electronic Provider Incentive Payment System... 9 epip Provider Registration State Level Attestation Attest to AIU Election Criteria Attest to Provider Type Criteria Attest to License & Sanctions Criteria Attest to Patient Volume Criteria Attest to Medicaid Patient Volume Criteria Attest to Medicaid Patient Volume Criteria Attest to Needy Individual Patient Volume Criteria Payment Status Medicaid EHR Incentive Program Acronyms Glossary General Glossary EP Page 3 of 37

4 Introduction EHR Incentive Program The American Recovery and Reinvestment Act of 2009 (ARRA or Recovery Act) provides for Electronic Health Record (EHR) Incentive Program payments to eligible professionals (EPs) and eligible hospitals (EHs) including critical access hospitals (CAH) participating in Medicare and Medicaid programs as they demonstrate adoption, implementation, upgrade or meaningful use of certified EHR technology. To facilitate the vision of transforming our nation s health care system to improve quality, safety and efficiency of care to EHR technology, the Health Information Technology for Economic and Clinical Health (HITECH) Act established programs under Medicare and Medicaid. The Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator (ONC) have released final rules to guide and implement the provisions of the Recovery Act. The New Hampshire Office of Medicaid Business and Policy (OMBP) is responsible for the implementation of New Hampshire s Medicaid EHR Incentive Program. Over the next 10 years, OMBP will disburse payments to providers who adopt, implement, upgrade or demonstrate meaningful use of certified EHR technology in their first year of participation in the program and successfully demonstrate meaningful use in subsequent years. These incentive programs are designed to support providers in this period of Health Information Technology (HIT) transition, accelerate the adoption of HIT and instill the use of qualified EHRs in meaningful ways to help our nation to improve the quality, safety and efficiency of patient health care. New Hampshire s Medicaid EHR Incentive Program Two key components of the Medicaid EHR Incentive Program are registration and attestation. The New Hampshire Department of Health and Human Services has fiduciary responsibility to ensure that Medicaid supplemental funds are disbursed accurately in compliance with federal and state regulations. Registration The registration process allows providers to participate in the Medicaid EHR Incentive Program. Providers must complete Federal- and State-level registration processes. Attestation The attestation process allows providers to attest to the Medicaid EHR Incentive Program s eligibility criteria as they demonstrate adoption, implementation, upgrade or meaningful use of EHR technology. Page 4 of 37

5 Provider Outreach & Recruitment The Regional Extension Center of New Hampshire (RECNH) is one of 62 RECs nationwide designated to serve New Hampshire as an unbiased, trusted resource with national perspective and local expertise to assist healthcare providers with EHR adoption, optimization and achievement of Meaningful Use. The RECNH serves as a neutral source for credible EHR and HIT information something much needed as healthcare providers seek to navigate EHR options and select vendors who meet new federal Meaningful Use requirements. The RECNH strives to fully identify and provide solutions to the challenges New Hampshire healthcare providers face in adopting EHR systems. Finally, and most important, the program provides critical, hands-on services for EHR adoption as outlined below. Regional Extension Center Services General and Technical Assistance Outreach and education Workforce support Tools and resources in all aspects of EHR and HIT Vendor selection and preferred pricing Project Management Practice and workflow redesign System implementation Interoperability and health information exchange (HIE) Privacy and security The RECNH has a unique national perspective and local expertise and is committed to building connection and collaboration among the state's healthcare community, ensuring that the individuals and organizations are connected to the right people, tools and resources to optimize success of EHRs and achievement of Meaningful Use of EHRs. To take advantage of the RECNH services, please contact them directly at: Regional Extension Center of New Hampshire c/o New Hampshire Medical Society 7 North State Street Concord NH Page 5 of 37

6 Federal Pre-Registration Getting Ready for Federal Registration Providers opting to receive Medicaid EHR Incentive Program payments must first register with the CMS Registration and Attestation System. Before registering, you must have the proper enrollment records in the appropriate systems. Let s look at the pre-registration activities that will prepare you for registration! We recommend completing the Federal Pre-Registration before completing the Federal Registration. Begin Here First! In order to register on the CMS Registration & Attestation System, you will need the following: Pre- Registration Checklist Tell Me More! NPI NPI NPPES STATE TIN National Provider Identifier (NPI) (unique identification number for covered health care providers) National Plan & Provider Enumeration System (NPPES) User ID & Password Medicaid EHR State (you decide if you will participate in the Medicaid EHR Incentive Program) Taxpayer Identification Number (TIN) (unique identification number used by IRS in the administration of tax law) The National Provider Identifier is a Health Insurance Portability and Accountability Act of 1996 (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health care providers. When covered health care providers, health plans, and health care clearinghouses submit claims/encounter data, they will use the NPI in the administrative and financial transactions adopted under HIPAA. To participate in the EHR Incentive Program, all EPs and EHs must have an active NPI. If you do not have an NPI, navigate to the CMS National Plan and Provider Enumeration System website to apply. The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of standard unique identifiers for health care providers and health plans. The purpose of these provisions is to improve the efficiency and effectiveness of the electronic transmission of health information. CMS has developed the National Plan and Provider Enumeration System to assign these unique identifiers. NPPES To participate in the EHR Incentive Program, all EPs and EHs must have an active NPPES web user account. Note: this is the same User ID and Password that is used to access PECOS, the Provider Enrollment, Chain and Ownership System. However, EPs that are only participating in the Medicaid EHR Incentive Program are not required to be enrolled in PECOS. If you do not have a NPPES account, navigate to the National Plan and Provider Enumeration System website to apply. I&A EPs may authorize surrogate users to work on behalf of the EP in the EHR Incentive Program Registration and Attestation System. Users working on behalf of an EP must have an Identity & Access Management (I&A) web user account (User ID/Password) and be associated to the EP s NPI. If you are working on behalf of an EP and do not have an I&A web user account, navigate to the I&A website to apply. Page 6 of 37

7 CMS Registration & Attestation System Federal Portal The CMS Registration and Attestation System web portal is used to facilitate the Medicare and Medicaid EHR Incentive Programs. To participate in the Medicaid EHR Incentive Program, providers must first complete a Federal-level registration process. Completing the Federal Registration is a prerequisite for completing the State Registration. CMS Registration & Attestation System Federal Registration Providers must register with the CMS Registration and Attestation System to commence the EHR Incentive Program process. If seeking the Medicaid EHR Incentive Program payment, providers must complete the state-level registration at the state s web portal. CMS Registration Successful Registrations Completed Federal Registrations are assigned a CMS Registration ID. You will need this to access the State Registration. Providers opting to receive Medicaid EHR Incentive Program payments from New Hampshire after successfully completing Federal Registration will be required to register with NH Medicaid s Electronic Provider Incentive Payment (epip) website. Providers may initiate the state registration process hours following Federal Registration. EPs may switch one-time between the Medicare and Medicaid EHR Incentive Programs over the duration of the entire EHR Incentive Program but this must occur before Refer to the CMS EHR Incentive Program website for more information on the Medicare EHR Incentive Program. Page 7 of 37

8 State Pre-Registration Getting Ready for State Registration Providers opting to receive Medicaid EHR Incentive Program payments from New Hampshire must register with NH Medicaid s EHR Electronic Provider Incentive Payment System (epip). Before registering, you must have the proper identification numbers. Let s look at the pre-registration activities that will prepare you for registration! We recommend completing the State Pre-Registration before completing the State Registration. Begin Here First! In order to register and attest on the Medicaid EHR epip, you will need the following: Pre- Registration Checklist Tell Me More! NH Medicaid Provider Number CMS Registration ID EHR Certification Number NPI TIN Unique identifier assigned by NH Medicaid to an accepted provider for participating in New Hampshire s Medicaid Program Unique number assigned by CMS Registration & Attestation System after completing the Federal Registration Unique number assigned by ONC-Authorized Testing & Certification Board after an EHR system has been successfully certified National Provider Identifier is the unique identification number assigned by CMS for covered health care providers. (If reassigning incentive payment, must also have Payee NPI.) Taxpayer Identification Number is the unique identification number used by IRS in the administration of tax law. (If reassigning incentive payment, must also have Payee TIN.) NH MEDICAID PROVIDER NUMBER To receive an EHR incentive payment, providers must be enrolled as an active New Hampshire Medicaid provider in good standing. To enroll in New Hampshire Medicaid, navigate to the New Hampshire Medicaid provider Enrollment website. The EHR Certification Number is assigned by Office of the National Coordinator-Authorized Testing & Certification Board (ONC-ATCB) after an EHR system has been successfully certified. EHR CERTIFICATION NUMBER To participate in the EHR Incentive Program, all EPs and EHs must have a CMS Certification Number for their EHR system. If you do not have an EHR Certification Number, navigate to the Office of the National Coordinator for Health Information Technology Certified Health IT Product List website. CMS REGISTRATION ID The CMS Registration ID is assigned by the CMS Registration & Attestation System after successfully completing the Federal Registration. You need this number in order to register at the state-level. To participate in the EHR Incentive Program, all EPs and EHs must have a CMS Registration ID. If you do not have a CMS Registration ID, navigate to the CMS Registration & Attestation System website. NPI The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act of 1996 (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health care providers. When covered health care providers, health plans, and health care clearinghouses submit claims/encounter data, they will use the NPI in the administrative and financial transactions adopted under HIPAA. To participate in the EHR Incentive Program, all EPs and EHs must have an active NPI. If you do not have an NPI, navigate to the CMS National Plan and Provider Enumeration System website to apply. Page 8 of 37

9 Electronic Provider Incentive Payment System State Portal Summary New Hampshire s Electronic Provider Incentive Payment System (epip) web portal is used to facilitate the Medicaid EHR Incentive Program. To participate in the Medicaid EHR Incentive Program, providers must complete a State-level registration process after successfully completing the Federal-level registration process. Completing the State Registration is a prerequisite for completing the State Attestation. Medicaid EHR Electronic Provider Incentive Payment System (epip) Step 1 Register Providers create an account and register with epip to initiate the Medicaid EHR Incentive Program. Step 2 Attest Providers enter data to meet attestation requirements to qualify for the Medicaid EHR Incentive Program. Step 3 Payment Providers may sign onto epip at any time to get a status of their payment. Once the provider completes the registration process, epip starts to report the account status. Page 9 of 37

10 epip Provider Registration Step 1 New Hampshire Medicaid providers must register on New Hampshire s Electronic Provider Incentive Payment System (epip) to initiate the Medicaid EHR Incentive Program. Completing the State Registration is a prerequisite for completing the State Attestation. epip State Level Registration Register State Registration Use this tab to perform the following functions: o Register for the Medicaid EHR Incentive Program o Terminate participation in the Medicaid EHR Incentive Program In order to complete registration, you must complete the following registration actions: Begin Here First! User Agreement User Identification User Validation User Web Account Items From State Pre- Registration Checklist In order to register on epip, you will need the following: New Hampshire Medicaid Provider Number CMS Registration ID EHR Certification ID NPI (if reassigning incentive payment, must also have Payee NPI) TIN (if reassigning incentive payment, must also have Payee TIN) Actions User Agreement Eligible Providers must submit an attestation that they are NH Medicaid Providers who agree to create an epip web account in order to participate in the Medicaid EHR Incentive Program. User Identification User Verification User Web Account Eligible Providers are required to provide identifying security data to gain access to the system. (i.e. NPI, TIN, CMS Registration ID and NH Medicaid Provider Number) Validate pre-filled data feed from CMS Registration & Attestation System (i.e., NPI, TIN, NH Medicaid Provider Number, Name, Business Address, , Phone, EHR Certification Number if known). If pre-filled data is incorrect, exit epip and either navigate to the CMS Registration & Attestation System or contact NH Medicaid Provider Enrollment at or by phone at (603) as appropriate to perform corrective action. epip Login & Password Provider enter NH Medicaid Provider Number as epip User Name Provider provides alternate contact name, phone & (optional) Provider creates epip User Password Page 10 of 37

11 State Level Attestation Step 2 Providers must meet attestation requirements to qualify for the Medicaid EHR Incentive Program. These are outlined in the table below and will be explained in detail in the following pages. To participate in the Medicaid EHR Incentive Program, providers must complete a State-level attestation process after successfully completing the State-level registration process. Re-attestation is required for each Medicaid EHR Incentive Program payment year. Completing the State Attestation is a prerequisite to obtaining a Medicaid EHR incentive payment. epip State Level Attestation Attest Begin Here First! Attestation Checklist State Attestation Use this tab to perform the following functions: o Attest for the Medicaid EHR Incentive Program o Modify existing attestation o View attestation summary In order to complete attestation, you must complete the following attestation actions: Adopt, Implement, Upgrade (AIU) Election Criteria Provider Type Criteria License & Sanctions Criteria Medicaid Patient Volume Threshold Criteria Needy Individuals Patient Volume Threshold Criteria [applicable to Federally Qualified Health Centers (FQHCs and Rural Health Centers (RHCs) only] There are other requirements for Physician Assistants (PAs) in FQHCs/RHCs, Pediatricians, and Group Practices and Clinics In order to attest on epip, you will need the following: AIU Type epip User Name & Password EHR Certification Number Medicaid Patient Encounters (NH and each Out-of-State) [those in which Medicaid (including the program formerly known as Healthy Kids Gold and out-of-state Medicaid and Medicaid-managed care programs) paid for part or all of the services (including premiums, co-payments, and/or cost-sharing)] Patient Volume Methodology (Individual or Aggregate) Patient Volume Reporting Period (a continuous 90-day period in the prior calendar year) Patient Volume Type (Medicaid Patient Volume or Needy Individual Patient Volume) Physician Type Provider Type Total Emergency Department Patient Encounters (hospital-based) Total Inpatient Hospital Patient Encounters (hospital-based) Total Patient Encounters Additionally, if in an FQHC/RHC: FQHC/RHC Facility Patient Encounters (in Practice Predominantly Reporting Period) FQHC/RHC PA Led Type FQHC/RHC Practice Predominantly Reporting Period (a 6-month period in prior calendar year) FQHC/RHC Total Needy Individual Patient Encounters [those in which Medicaid (including the program formerly known as Healthy Kids Gold and out-of-state Medicaid and Medicaid-managed care programs) paid for part or all of the services (including premiums, co-payments, and/or cost-sharing); OR CHIP (the program formerly known in NH as Healthy Kids Silver ) paid for part or all of the services (including premiums, co-payments, and/or cost-sharing); OR Services were rendered to an individual on a sliding scale; OR Services were uncompensated] FQHC/RHC Total Patient Encounters (in FQHC/RHC Practice Predominantly Reporting Period) Page 11 of 37

12 Attest to AIU Election Criteria Step 2a Eligible Providers must obtain certified EHR technology and attest to Adoption, Implementation or Upgrade (AIU) of their system in order to participate in the first year of the Medicaid EHR Incentive Program. Criteria Completing the State Attestation is a prerequisite for determining the Medicaid EHR Incentive payment. AIU Election A AIU Attestation Requirement Adoption of an EHR system requires that a provider acquired, purchased or secured access to certified EHR technology. AIU Documentation Requirement A copy of the vendor contract, paid invoice, purchase order or a document showing a legal contractual obligation verifying the provider acquired, purchased or secured access to certified EHR technology. Select Adoption, Implementation or Upgrade (AIU) Attestation Requirement Exceptions Ineligible I U Implementation of an EHR system requires that a provider installed or commenced utilization of certified EHR technology. Upgrade of an EHR system requires that a provider upgraded from existing EHR technology to certified EHR technology or expanded the functionality of existing certified EHR technology. A copy of the vendor contract, paid invoice, purchase order or a document showing a legal contractual obligation verifying the provider installed certified EHR technology. A copy of the vendor contract, paid invoice, purchase order or a document showing a legal contractual obligation verifying the provider upgraded to certified EHR technology or expanded functionality of the existing certified EHR technology. AIU Type: Eligible Professional selects one of the above AIU methods EHR Certification Number: Eligible Professional enters after obtaining from ONC-ATCB YES Eligible Professional selects attestation method or Eligible Professional provides EHR Certification Number NO Eligible Professional uploads proof of AIU compliance None Providers without proof of AIU are not eligible for the Medicaid EHR Incentive Program Definitions Eligible Professionals receive payments based on the calendar year (January 1 through December 31). AIU attestation requires the provider to obtain certified EHR technology for the first calendar year of participation. Meaningful Use (MU) attestation (which EPs are required to attest to in order to receive subsequent payments after Year 1) requires the provider to provide quantitative measures to substantiate meaningful use for a contiguous reporting period of 90 days for the first Meaningful User calendar year (MU1) and the entire calendar year for subsequent MU years. Page 12 of 37

13 Attest to Provider Type Criteria Step 2b Providers must meet a specific Provider Type eligibility requirement to qualify for the Medicaid EHR Incentive Program. Criteria Completing the State Attestation is a prerequisite for determining the Medicaid EHR Incentive payment. Provider Eligibility Criteria Select Type of Eligible Professionals (EP) Eligible Professionals (EPs) are: o Physicians (Doctor of Medicine, Doctor of Osteopathy) o Dentists o Nurse Practitioners o Certified Nurse Midwives o Physician Assistants (PAs) practicing in an FQHC/RHC led by a PA Provider Type: Provider s selection feeds from the CMS Registration & Attestation System Attestation Requirement Exceptions YES or NO None EP attests to meeting one of the above provider types Ineligible Provider Types not listed are not eligible for the Medicaid EHR Incentive Program Additional Requirements for Physician Assistants in FQHCs/RHCs In addition to the above provider eligibility requirement, PAs in FQHCs/RHCs must meet the following criteria to qualify to participate in the Medicaid EHR Incentive Program. Physician Assistant (PA) Eligibility Criteria Select Type of PA Led All PAs who furnish services in an FQHC/RHC are eligible if they practice in an FQHC/RHC that is led by a PA. The PA who leads the FQHC/RHC must satisfy one of the following requirements: o PA is the primary provider in a clinic (example: part-time physician and full-time PA) o PA is a clinical or medical director at a clinical site of practice o PA is an owner of an RHC PA Led Type: Provider s selection feeds from the epip Registration module Attestation Requirement Exceptions Ineligible YES or NO None o PA attests to meeting one of the above PA provider types PAs not in FQHCs/RHCs that are led by a PA are not eligible for the Medicaid EHR Incentive Program Page 13 of 37

14 Attest to License & Sanctions Criteria Step 2c Eligible Providers must have the proper licenses/certifications and not have active unresolved sanctions. NH Medicaid will use existing operational protocols to validate licensure and sanctions. Criteria Completing the State Attestation is a prerequisite for determining the Medicaid EHR Incentive payment. Provider Eligibility Criteria License & Sanctions Eligible Provider must be an active NH Medicaid Provider in good standing License Eligible Provider has proper license/certification Sanctions Eligible Provider does not have current sanctions Attestation Requirement YES or NO Eligible Provider attests to possessing proper license/certification Eligible Provider attests to clearance of any sanctions Exceptions None Ineligible Non-licensed Providers are not eligible for the Medicaid EHR Incentive Program Providers with sanctions are not eligible for the Medicaid EHR Incentive Program Definitions Eligible Providers must meet licensure/certification requirements applicable to their provider type as required by the professional licensing and certification boards or entities and as specified by federal and state statutes and regulations. Eligible Providers may be sanctioned by NH Medicaid for violations of the terms of the NH Medicaid Provider Agreement. Sanctions may be imposed due to fraudulent or abusive conduct on the part of the NH Medicaid provider. Sanctions must be resolved before disbursement of an EHR Incentive Program payment. Page 14 of 37

15 Attest to Patient Volume Criteria Step 2d New Hampshire s Medicaid EHR Incentive Program has adopted CMS Patient Encounter Methodology. Eligible Professionals are required to meet a specific patient volume threshold each payment year to be eligible for the Medicaid EHR Incentive Program. EP measurements are based on Medicaid Patient Volume Type or Needy Individual Patient Volume Type. EPs in FQHCs/RHCs have a special option of qualifying using either the Medicaid Patient Volume Type or Needy Individual Patient Volume Type. All other EP measurements are based on the Medicaid Patient Volume Type. Pediatricians have a special exception in meeting the patient volume. Criteria Completing the State Attestation is a prerequisite for determining the Medicaid EHR Incentive payment. Understanding Provider Options EPs must determine the following before proceeding Patient Volume Elements Physician Type Patient Volume Type Patient Volume Methodology Selection feeds from the NH Medicaid database Pediatrician Non-Pediatrician Select One: Medicaid Patient Volume {All EPs} Needy Individual Patient Volume {EPs in FQHCs/RHCs } Select One: Individual Patient Volume Methodology Aggregate Patient Volume Methodology Definitions Physician Type is classified as Pediatrician or Non-Pediatrician for purposes of the Medicaid EHR Incentive Program. This distinction is needed because Pediatricians have a special exception to satisfy an optional patient volume threshold. Patient Volume Type is the technique used to perform measurements. EPs participating in the Medicaid EHR Incentive Program must select either Medicaid Patient Volume or Needy Individual Patient Volume. o Medicaid Patient Volume is the percentage of encounters in which Medicaid (including the program formerly known as Healthy Kids Gold and out-of-state Medicaid and Medicaid-managed care programs) paid for part or all of the services (including premiums, co-payments, and/or cost-sharing). All EPs can select this option. o Needy Individual Patient Volume is the percentage of encounters in which Medicaid (including the program formerly known as Healthy Kids Gold and out-of-state Medicaid and Medicaid-managed care programs) paid for part or all of the services (including premiums, co-payments, and/or cost-sharing); OR CHIP (the program formerly known in New Hampshire as Healthy Kids Silver ) paid for part or all of the services (including premiums, co-payments, and/or cost-sharing); OR Services were rendered to an individual on a sliding scale; OR Services were uncompensated. Only EPs in FQHCs/RHCs can select this option. Patient Volume Methodology is the way in which EPs report their patient volume. EPs have the option of selecting either the Individual or Aggregate Patient Volume Methodology. o Individual is the sum of patient encounters for a single EP. o Aggregate is the sum of patient encounters for the entire practice (includes all providers that bill for Medicaid, even those that are not eligible as an EP for the Medicaid EHR Incentive Program). Page 15 of 37

16 Attest to Medicaid Patient Volume Criteria Step 2d 1 Medicaid Patient Volume is based on the percentage of the provider s Medicaid Patient Encounters. Medicaid Patient volume is not impacted by, or related to, how providers are billed. Providers selecting this option must determine their Patient Volume Methodology and satisfy the Non-Hospital Based Criteria. Criteria Completing the State Attestation is a prerequisite for determining the Medicaid EHR Incentive payment. Provider Eligibility Criteria EP reports Medicaid Patient Encounters and Total Patient Encounters in Patient Volume Reporting Period Physician Type Patient Volume Type Selection feeds from the NH Medicaid database Pediatrician Non-Pediatrician Medicaid Patient Volume Patient Volume Patient Volume Methodology Patient Volume Reporting Period: Select One: Individual Patient Volume Methodology Aggregate Patient Volume Methodology A continuous 90-day period in the prior Calendar Year A Numerator Medicaid Patient Encounters B Denominator Total Patient Encounters Number of unique patient encounters in denominator in which Medicaid (including the program formerly known as Healthy Kids Gold and out-of-state Medicaid and Medicaid-managed care programs) paid for part or all of the services (including premiums, copayments, and/or cost-sharing) Number of all unique total patient encounters in Patient Volume Reporting Period Patient Volume Threshold Percentage epip calculates: [A / B] x 100 Attestation Requirement YES or NO EP attests to meeting the provider type patient volume threshold EP attests to selected Patient Volume Methodology 1. *Pediatricians have special eligibility and payment rules. 2. *EPs in a Group Practice or Clinic are permitted to use the Group Practice or Clinic s aggregate patient volume as a proxy for their own under special conditions. Exceptions Ineligible 3. Eligible Providers can optionally include out-of-state patient encounters in their eligible patient volume threshold; these should be reported separately for each state (numerator and denominator information must be included). This will trigger an eligibility verification audit and require OMBP to contact the other state(s) to confirm patient encounter data. This may delay payment until the data is properly validated. *See Additional Requirements EPs not meeting the provider type patient volume threshold or selecting different methodologies within the Practice are not eligible for the Medicaid EHR Incentive Program Page 16 of 37

17 Attest to Medicaid Patient Volume Criteria Definitions For purposes of calculating the Medicaid Patient Volume, Medicaid Patient Encounters are services rendered to an individual on any one day where Medicaid (including the program formerly known as Healthy Kids Gold and outof-state Medicaid and Medicaid-managed care programs) paid for part or all of the service (individual s premiums, copayments and/or cost-sharing). EPs may choose one (or more) clinical sites of practice in order to calculate their patient volume. This calculation does not need to be across all of an EP s sites of practice. However, at least one of the locations where the EP is adopting or meaningfully using certified EHR technology should be included in the patient volume. In other words, if an EP practices in two locations, one with certified EHR technology and one without, the EP should include the patient volume at least at the site that includes the certified EHR technology. When making an individual patient volume calculation, an EP may calculate across all practice sites, or just at the one site. Any Eligible Professional demonstrating meaningful use must have at least 50% of their patient encounters during the EHR reporting period at a practice/location or practices/locations equipped with certified EHR technology capable of meeting all of the meaningful use objectives. The Medicaid Patient Volume Threshold percentage is defined as the total Medicaid Patient Encounters in any representative continuous 90-day period in the preceding year, divided by the total of all patient encounters in the same 90-day period, multiplied by 100. The qualifying patient volume thresholds for the Medicaid EHR Incentive Program are given in the following: Entity Minimum 90-day Medicaid Patient Volume Threshold Physicians 30% Pediatricians 30% or optional 20% Dentists 30% Certified Nurse Midwives 30% Physician Assistants when practicing at an FQRC/RHC led by a Physician Assistant 30% Nurse Practitioner 30% Or the Medicaid EP practices predominantly in an FQHC or RHC 30% needy individual patient volume threshold For purposes of Medicaid EHR Incentive Program eligibility, Eligible Professionals include the above provider types who are legally authorized to practice their profession under federal and state law and treat and diagnose illness and injuries for New Hampshire Medicaid members under the New Hampshire Medicaid program. The EP must be a New Hampshire Medicaid Provider who meets one of the following requirements within the scope of his/her practice rules: o o o o Physician who holds a Doctor of Medicine or Doctor of Osteopathy degree, holds a current license, and is board certified in medicine Physician classified as a Pediatrician who holds a Doctor of Medicine or Doctor of Osteopathy degree, holds a current license, and is board certified in pediatric medicine. A pediatrician s provider enrollment with New Hampshire Medicaid must indicate pediatrician as a specialty OR the provider must be a member of the American Academy of Pediatrics. Dentist who holds a Doctor of Dental Surgery or Dental Medicine degree, holds a current license, and is board certified in dentistry Mid-Level Practitioners who hold a current license and applicable board certification for provider types below: o Certified Nurse Midwives o Physician Assistants when practicing at an FQRC/RHC led by a Physician Assistant o Nurse Practitioner Page 17 of 37

18 Attest to Medicaid Patient Volume Criteria Step 2d 1 (Continued) Individual Patient Volume Methodology Examples Example 1: Dr. Barry, an OBGYN, had 80 Medicaid patient encounters out of 200 total encounters in the selected 90-day period. o Numerator = the sum of all Medicaid patient encounters in a continuous 90-day period in the preceding calendar year = 80 o Denominator = the sum of all encounters in the same continuous 90-day period = 200 o [(Numerator / Denominator) X 100]. If the percentage is 30% or higher, then the EP may be eligible for a Medicaid EHR incentive payment: 80/200 X100 = 40% Medicaid patient volume. Dr. Barry meets this criterion. Example 2: Dr. Powers, a primary care physician, had 30 Medicaid patient encounters out of 300 total encounters in the selected 90-day period. o Numerator = 30 o Denominator = 300 o [(30/300) X100] = 10% patient volume. Dr. Powers does NOT meet this criterion. Additional Requirements Pediatricians For purposes of determining Medicaid EHR Incentive Program eligibility, Pediatricians are physicians who treat and diagnose illness and injuries in children under the New Hampshire Medicaid program. A Pediatrician must be a New Hampshire Medicaid Provider who meets the physician scope of practice rules, holds a Doctor of Medicine or Doctor of Osteopathy degree, holds a current license, and is board certified in Pediatrics. A pediatrician s provider enrollment with New Hampshire Medicaid must indicate pediatrician as a specialty OR the provider must be a member of the American Academy of Pediatrics. Pediatricians have a special exception to satisfy either: o a minimum 20% patient volume (to receive 2/3 of the Medicaid EHR Incentive Program payment) or o a minimum 30% patient volume (to receive the full Medicaid EHR Incentive Program payment) Additional Requirements Group Practices or Clinics EPs in a Group Practice or Clinic, referred to below as Practice, who use the Practice s data, must decide if each provider will use the EP s Individual Patient Volume or the Practice s Aggregate Patient Volume Methodology. If using the Individual Patient Volume Methodology, data is based on the sum of patient encounters for a single EP. If using the Aggregate Patient Volume Methodology, data is based on the sum of patient encounters for the entire Practice (includes all providers that bill Medicaid, even those that are not eligible for incentive payments under the Medicaid EHR Incentive Program) but can only be used as a proxy for all EPs in the Practice if all of the following Federal and State specific rules are met: Page 18 of 37

19 Attest to Medicaid Patient Volume Criteria Step 2d 1 (Continued) Aggregate Patient Volume Methodology Conditions Federal Specific Rules State Specific Rules 1. Practice s patient volume is appropriate as a patient volume methodology calculation for the EP (i.e., if an EP only sees Medicare, commercial or self-pay patients, this is not an appropriate calculation) 2. There is an auditable data source to support the Practice's patient volume determination 3. All of the EPs in the Practice must use the same methodology for the payment year (i.e., clinics could not have some EPs use their individual patient volume for patients seen at the clinic, while others use the clinic-level data.) 4. The Practice uses the entire Practice s patient volume and does not limit patient volume in any way 1. All EPs in the practice must use the same aggregate patient volume data for the payment year 2. EPs employed during the payment year are permitted to use the Practice s aggregate patient volume data if meeting the Federal Specific Rules. In the event of an audit, the Practice and the EP must successfully demonstrate these EPs have satisfied these requirements during the payment year The following are other criteria pertaining to the aggregate calculation: o If an EP works both inside and outside of the Practice, then the Patient Volume Calculation includes only those encounters associated with the Practice and not the EP s outside encounters. o Each Practice can include the encounters made by the EP at its own Practice in the aggregate calculation, however, the EP can register for only one incentive payment (i.e., the EP cannot register for an incentive payment at every Practice that uses his/her encounter information in its group calculation). o If two providers in the Practice provide services to the same Medicaid patient on the same day, then for purposes of the aggregate calculation, multiple encounters for the same Medicaid patient on the same day may be counted. On behalf of the Practice, the Office Manager/Administrator must submit the Establish Practice Request Form (located on the New Hampshire Medicaid EHR website) to OMBP to establish the Practice in the epip System and provide the following information before an EP can begin State-level attestation in epip: o Letterhead with Practice s New Hampshire Medicaid Provider Number, AIU Election, EHR Certification Number, Patient Volume Methodology, Aggregate Medicaid Patient Encounters, Aggregate Total Patient Encounters o Proof of AIU compliance o List of each EP within the Practice showing name, New Hampshire Medicaid Provider Number, and Provider Type o List of non-ep provider within the Practice (those that bill Medicaid) showing name, New Hampshire Medicaid Provider Number, and National Provider Identified (NPI) Please note that failure to perform the above procedures will prevent an EP from completing attestation; cause submission of an incorrect attestation; and delay, or cause denial of, payment. Aggregate Patient Volume Methodology Example Calculate the Medicaid Aggregate Patient Volume based on all providers in the Practice who bill Medicaid (even those not designated as EPs) in the selected 90-day period: Page 19 of 37

20 Attest to Medicaid Patient Volume Criteria Step 2d 1 (Continued) Provider Name Category EP Status Medicaid Patient Total Patient Encounters Encounters Dr. Smith MD Yes Casey Jones NP Yes Jamie Doe RN No Logan Shaw PharmD No Dr. Moore MD Yes Dr. Johnson DDS Yes Total 415 1,200 o o o Numerator = the sum of all Medicaid patient encounters from all Medicaid providers (even those that aren't designated as EPs, and, hence, aren t eligible for the incentive program) in a continuous 90-day period: = 415 Denominator = the sum of all encounters from all providers (even those that aren't eligible for the incentive program) in the Practice in a continuous 90-day period. Note: to use the Aggregate Practice calculation, every provider in the Practice must provide services to needy individuals: = 1,200 [(Numerator / Denominator) X 100]. If the percentage is 30% or higher (optional 20% for pediatricians), then the EP may be eligible for a Medicaid EHR incentive payment: [(415/1,200) X 100] = 35% patient volume clinic/group practice-wide. Since this exceeds the 30% threshold, Dr. Smith, Casey Jones, Dr. Moore, Dr. Johnson, and Dr. Hayes are EPs who meet the patient volume eligibility criterion. Page 20 of 37

21 Attest to Medicaid Patient Volume Criteria Step 2d 1.1 Additional Requirements Non-Hospital Based Eligible Professionals EPs selecting the Medicaid Patient Volume Type cannot be hospital-based. Each EP s patient encounters will be evaluated to determine if rendered services in a hospital-based place of service exceeds the more than 90% threshold percentage. Completing the State Attestation is a prerequisite for determining the Medicaid EHR Incentive Program payment. Provider Eligibility Criteria EP reports Hospital-Based Patient Encounters and Total Encounters in prior calendar year Hospital Based Percentage Hospital-based Reporting Period: A B Total Inpatient Hospital Patient Encounters Total Emergency Department Patient Encounters Hospital-Based Patient Encounters C Numerator Hospital-Based Patient Encounters D Denominator Total Patient Encounters Calendar year prior to payment year Number of all unique inpatient hospital patient encounters in numerator Number of all unique emergency department patient encounters in numerator epip calculates: A + B = C Number of unique hospital-based patient encounters in denominator Number of all unique patient encounters in reporting period Hospital-Based Percentage epip calculates: [C / D] * 100 Attestation Requirement YES or NO EP attests to meeting Non-Hospital Based criteria Exceptions Ineligible Not applicable to FQHC/RHC EPs utilizing the Needy Individual Patient Volume Criteria EPs with more than 90% of their patient encounters in a hospital-based place of service are not eligible for the Medicaid EHR Incentive Program Definitions For purposes of determining Medicaid EHR Incentive Program eligibility, Hospital-based EPs have more than 90 percent of their covered professional services in a hospital setting and therefore do not qualify for the Medicaid EHR Incentive Program. A hospital setting is an inpatient hospital place of service or an emergency department place of service. Hospital-Based Patient Encounters are encounters received at Place of Services codes for HIPPA standard transactions: 21 Inpatient Hospital and/or 23 Emergency Department. Page 21 of 37

22 Attest to Needy Individual Patient Volume Criteria Step 2d 2 Medicaid Patient Volume is based on the percentage of the provider s Needy Individual Patient Encounters. Only EPs in an FQHC/RHC can select this option. Needy Individual Patient volume is not impacted by, or related to, how providers are billed. Providers selecting this option must determine their Patient Volume Methodology and satisfy the Practice Predominantly Criteria. Criteria Completing the State Attestation is a prerequisite for determining the Medicaid EHR Incentive payment. Provider Eligibility Criteria - FQHC/RHC EP Patient Encounters Needy Individual Patient Volume EP reports Needy Individual Patient Encounters and Total Patient Encounters in Patient Volume Reporting Period Physician Type Patient Volume Type Patient Volume Methodology Patient Volume Reporting Period: A B C Selection feeds from the NH Medicaid database Pediatrician Non-Pediatrician Needy Individual Patient Volume {EPs in FQHCs/RHCs only} Select One: Individual Patient Volume Methodology Aggregate Patient Volume Methodology A continuous 90-day period in the prior calendar year Total Needy Individual Patient Encounters Number of unique Medicaid patient encounters in numerator in which Medicaid (including the program formerly known as Healthy Kids Gold and out-of-state Needy Individual Medicaid Patient Encounters Medicaid and Medicaid-managed care programs) paid for part or all of the services (including premiums, copayments, and/or cost-sharing) Number of unique CHIP (the program formerly known in NH as Healthy Kids Silver ) patient encounters in numerator in which CHIP (the program formerly known Needy Individual CHIP Patient Encounters in NH as Healthy Kids Silver ) paid for part or all of the services (including premiums, co-payments, and/or costsharing) Number of unique patient encounters in numerator in Needy Individual Patients Paying Below Cost which services were rendered to an individual on a sliding Patient Encounters scale or services were uncompensated Total Needy Individual Patient Encounters epip calculates: A + B + C= D FQHC/RHC Patient Volume Threshold Percentage D Numerator Total Needy Individual Patient Encounters Number of unique needy individual patient encounters in Patient Volume Reporting Period E Denominator Total Patient Encounters Number of all unique total patient encounters in Patient Volume Reporting Period Patient Volume Threshold Percentage epip calculates: [D / E] * 100 Attestation Requirement YES or NO EP attests to meeting the provider type patient volume threshold EP attests to selected Patient Volume Methodology Page 22 of 37

23 Attest to Needy Individual Patient Volume Criteria Step 2d 2 (Continued) Provider Eligibility Criteria - FQHC/RHC EP Patient Encounters 1. *Pediatricians have special eligibility and payment rules. 2. *EPs in a Group Practice or Clinic are permitted to use the Group Practice or Clinic s aggregate patient volume as a proxy for their own under special conditions. Exceptions Ineligible 3. Eligible Providers must include out-of-state patient encounters in their eligible patient volume threshold and report each state s Medicaid encounters separately. This will trigger an eligibility verification audit and require OMBP to contact the other state(s) to confirm patient encounter data. This will delay payment until the data is properly validated. *See Additional Requirements EPs not meeting the patient volume threshold or selecting different methodologies within the Practice are not eligible for the Medicaid EHR Incentive Program Definitions For purposes of calculating Needy Individual Patient Volume, Needy Individual Patient Encounters are services rendered to an individual on any one day in which Medicaid (including the program formerly known as Healthy Kids Gold and out-of-state Medicaid and Medicaid-managed care programs) paid for part or all of the services (including premiums, co-payments, and/or cost-sharing); OR CHIP (the program formerly known in New Hampshire as Healthy Kids Silver ) paid for part or all of the services (including premiums, co-payments, and/or cost-sharing); OR Services were rendered to an individual on a sliding scale; OR Services were uncompensated. EPs may choose one (or more) clinical sites of practice in order to calculate their patient volume. This calculation does not need to be across all of an EP s sites of practice. However, at least one of the locations where the EP is adopting or meaningfully using certified EHR technology should be included in the patient volume. In other words, if an EP practices in two locations, one with certified EHR technology and one without, the EP should include the patient volume at least at the site that includes the certified EHR technology. When making an individual patient volume calculation, an EP may calculate across all practice sites or just at the one site. The Needy Individual Patient Volume Threshold percentage is defined as the total Needy Individual Patient Encounters in any representative continuous 90-day period in the preceding year, divided by the total of all patient encounters in the same 90-day period, multiplied by 100. The qualifying patient volume thresholds for the Medicaid EHR Incentive Program are given in the following: Entity Minimum 90-day Medicaid Patient Volume Threshold Physicians 30% Pediatricians 30% or optional 20% Dentists 30% Certified Nurse Midwives 30% Physician Assistants when practicing at an FQRC/RHC led by a Physician Assistant 30% Nurse Practitioner 30% Or the Medicaid EP practices predominantly in an FQHC or RHC 30% needy individual patient volume threshold Page 23 of 37

24 Attest to Needy Individual Patient Volume Criteria Step 2d 2 (Continued) For purposes of Medicaid EHR Incentive Program eligibility, Eligible Professionals includes the above provider types who are legally authorized to practice their profession under federal and state law and treat and diagnose illness and injuries for New Hampshire Medicaid members under the New Hampshire Medicaid Program. The EP must be a New Hampshire Medicaid Provider who meets one of the following requirements within the scope of their practice rules: o o o o Physician who holds a Doctor of Medicine or Doctor of Osteopathy degree, holds a current license, and is board certified in medicine Physician classified as a Pediatrician who holds a Doctor of Medicine or Doctor of Osteopathy degree, holds a current license, and is board certified in pediatric medicine. A pediatrician s provider enrollment with New Hampshire Medicaid must indicate pediatrician as a specialty OR the provider must be a member of the American Academy of Pediatrics. Dentist who holds a Doctor of Dental Surgery or Dental Medicine degree, holds a current license, and is board certified in dentistry Mid-Level Practitioners who hold a current license and applicable board certification for provider types below: o Certified Nurse Midwives o Physician Assistants when practicing at an FQRC/RHC led by a Physician Assistant o Nurse Practitioner Individual Patient Volume Methodology Examples Example 1: Dr. Barry, an OBGYN, had 80 needy individual patient encounters out of 200 total encounters in the selected 90-day period. o Numerator = the sum of all needy individual patient encounters in a continuous 90-day period in the preceding calendar year = 80 o Denominator = the sum of all encounters in the same continuous 90-day period = 200 o [(Numerator / Denominator) X 100]. If the percentage is 30% or higher, then the EP may be eligible for a Medicaid EHR incentive payment: 80/200 X100 = 40% needy individual patient volume. Dr. Barry meets this criterion. Example 2: Dr. Powers, a primary care physician, had 30 needy individual patient encounters out of 300 total encounters in the selected 90-day period. o Numerator = 30 o Denominator = 300 o [(30/300) X100] = 10% needy individual patient volume. Dr. Powers does NOT meet this criterion. Additional Requirements Pediatricians For purposes of determining Medicaid s EHR Incentive Program eligibility, Pediatricians are physicians who treat and diagnose illness and injuries in children under the New Hampshire Medicaid program. As such, Pediatricians must be a New Hampshire Medicaid Provider who meets the physician scope of practice rules, hold a Doctor of Medicine or Doctor of Osteopathy degree, and hold a current license and is board certified in Pediatrics. Further, a pediatrician s provider enrollment with New Hampshire Medicaid must indicate that one of his/her specialties is a pediatrician OR the provider must be a member of the American Academy of Pediatrics. Page 24 of 37