Last Updated: 1/6/2016 Page 1 of 9

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1 Instructions for Completing the Compass PTN Participating Clinician NPI Excel Template, Online Participation Agreement Charter and Business Associate Agreement (BAA) Last Updated: 1/6/2016 Page 1 of 9

2 Table of Contents Introduction... 3 Instructions for Completing the Compass PTN Participating Clinician National Provider Identifier (NPI) Excel Template*... 4 Instructions Online Participation Agreement Charter*... 7 Instructions Business Associate Agreement (BAA)*... 9 Last Updated: 1/6/2016 Page 2 of 9

3 Introduction On September 29, 2015, Iowa Healthcare Collaborative (IHC) was one of 39 organizations selected by the Center for Medicare & Medicaid Innovation to participate in the Transforming Clinical Practice Initiative (TCPI), a national initiative designed to help clinicians achieve large-scale health transformation in primary and specialty care practice settings. The TCPI model establishes Practice Transformation Networks (PTN) that will assist clinicians in improving the way they deliver care by providing technical assistance support for integrating quality and process improvement, and by building on and spreading existing change methodologies, practice transformation tools, published literature, and technical assistance programs. Established by the IHC, the Compass Practice Transformation Network (Compass PTN) supports more than 7,000 clinicians across six states Georgia, Iowa, Kansas, Nebraska, Oklahoma and South Dakota who are committed to expanding quality improvement capacity in their primary and specialty care practices, share clinical best practices and achieve common goals of improved care, better health and reduced cost. This document will assist you in completing the enrollment process to become part of the Compass PTN and the larger national TCPI. Participation Agreement for providers and practices to commit to this initiative. Please note that participation in the Compass PTN and TCPI is completely voluntary and is at no cost to clinicians. The webpage and database you will use to submit enrollment information (described in this document) is secure. The information collected will only be used by the Iowa Healthcare Collaborative and the Compass PTN for tracking participation, reporting basic enrollment information to the Center for Medicare & Medicaid Innovation and related staff. Under no circumstances will your information will not be used, provided or sold to a third party. If you need any assistance or have questions about completing the Compass PTN enrollment process, please contact Ashley Thompson, Compass PTN Program Director, at thompsona@ihconline.org or (515) Last Updated: 1/6/2016 Page 3 of 9

4 Instructions for Completing the Compass PTN Participating Clinician National Provider Identifier (NPI) Excel Template* *Please note: This is required information. 1. Download the Compass PTN Participating Clinician NPI excel template, which can be found online at 2. After saving the template to your computer, complete the following information for each clinician/provider in your practice: Excel Title Organization Legal Name Organization NPI, if applicable Clinician/Provider NPI Clinician Last Name Clinician First Name Clinician Credential(s) Clinician Primary Medical Specialty Clinician First Secondary Medical Specialty Clinician First Secondary Medical Specialty Unique Group PAC ID Total Number of Clinicians Based on Group PAC ID Description Organization Legal Name as it is registered in the Medicare Enrollment, Chain, and Ownership System (PECOS). This can be left blank if provider is not associated with a group practice. Organization National Provider Identifier applicable for organizations such as federally-qualified health centers (FQHC), rural health clinics (RHC), etc. Unique Professional National Provider Identifier assigned by the National Plan & Provider Enumeration System (NPPES) Last Name of clinician, as registered in PECOS First Name of clinician, as registered in PECOS Medical credential(s) for the provider, such as MD, DO, DPM, ARNP, PA, etc. Primary medical specialty reported by clinician, such as Internal Medicine, etc. (Required) First secondary medical specialty reported by clinician (Optional) Second secondary medical specialty reported by clinician (Optional) Unique Group Practice ID assigned by PECOS to the Group Practice that the clinician works with (leave blank if the practice is not linked to a Group Practice) Total number of individual professionals based on Group PAC ID Organization Address Line 1 Group practice/clinician address line 1 Organization Address Line 2 Group practice/clinician address line 2 City State Zip Code Group practice/clinician city Group Practice/clinician state Group Practice/clinician zip code 3. Please save your excel document often. Last Updated: 1/6/2016 Page 4 of 9

5 4. Once you have entered your clinician information, please delete the example row in the template. A screenshot of the row (highlighted in yellow) that needs to be deleted is shown below: 5. IMPORTANT: After completing the template, please save it either as a.xls file/excel workbook or a.xlsx/excel workbook. In order for the Compass PTN to receive your completed template, you must save your file in one of these formats in order for. A screenshot of how to save the excel template to your computer in the correct format is shown below: a. Saving the template as a.xls file/excel workbook: b. Saving the template as a.xlsx file/excel workbook: Last Updated: 1/6/2016 Page 5 of 9

6 6. After you complete the online Compass PTN Participation Agreement Charter (instructions are in the next section of this document) you will need to attach the excel document. A screenshot of how to attach the excel template at the end of the charter is shown below: a. To attach the excel document to the online participation agreement charter click the Browse button. b. Upload your excel document. c. After uploading, your document name will appear to the right of the Browse button. d. Click Submit Last Updated: 1/6/2016 Page 6 of 9

7 Instructions Online Participation Agreement Charter* *Please note: This is required information for this initiative. 1. The Compass PTN Online Participation Agreement Charter must be completed online at 2. Begin by filling in Practice Information: a. Practice Name: Enter the business name of your practice. The business name refers to how your practice is referenced in marketing, advertising or verbally to patients. b. Practice Taxpayer Identification Number (TIN): Enter the practice s 9-digit TIN. Please enter the TIN without dashes, spaces or other non-numeric values. c. Practice Contact Person: This should be the main contact for the practice, such as a Clinic Manager, Clinic Administrator or other designated individual. d. Practice Contact Person Enter the Practice Contact Person s preferred address for communication. e. Practice Person Phone (with area code): Enter the Practice Contact Person s preferred phone number with area code. Enter the phone number in the following format EXAMPLE: f. Practice Address: Enter the physical building/location address of the practice. Enter any additional information such as Suite, Unit or other identifying information, if applicable EXAMPLE: 1234 Main Street, Suite 999 g. City: Enter the city where the physical building of the practice is located. h. State: From the drop-down menu, select the state where the physical building of the practice is located. i. Zip Code: Enter the zip code where the physical building of the practice is located. Depending on the location, the zip code may be a 5- or 9 digit entry EXAMPLES: (5-digit zip code entry) or (9- digit zip code entry) Last Updated: 1/6/2016 Page 7 of 9

8 j. Practice County: Enter the county where the physical building of the practice is located. k. Additional Practice Sites: If the practice has any satellite locations or other locations where care you/your clinician(s) deliver care, please list the Practice Name, City and State for each physical location. Then, once you have completed the information listed in items a-j above, you will need to complete these items for each additional practice site listed. l. Select your PTN Partner from the list below: From the drop-down menu, select the Compass PTN state partner that your practice would like as your primary point of contact for the PTN work. For most clinics, the PTN partner will likely be the organization that is based in your state. For example, clinics in Kansas will likely select Kansas Healthcare Collaborative for their PTN Partner. 3. Review the Participation Agreement Section As part of this initiative, I understand that my practice will be expected to: a. This is an important step, as this section reviews the general goals of the PTN and responsibilities of participation. Please note that part of the work of the Compass PTN will be to assist clinicians in achieving items listed in this section throughout the course of the initiative and it is not expected that participating clinicians will be performing all of the items in this section immediately. 4. After reading the responsibilities of participation, continue to the next section Fill out the Following Information. This section will ask you about your current Electronic Health Record (EHR) status (if any), your ability to run data reports, connection with community-wide health information exchange, data sharing, and participation in other efforts. Your answers to these questions will better help the Compass PTN understand the best types of support and resources to provide to you. 5. You will be required to submit an electronic signature after reading through and filling in the required information on this form. 6. IMPORTANT: After filling in your information, please do not hit the Submit button until you attach your completed Compass PTN Participating Clinician NPI excel template. Please go to pages 3-5 of this document for instructions. 7. After you have attached the excel template, hit the Submit button. Last Updated: 1/6/2016 Page 8 of 9

9 Instructions Business Associate Agreement (BAA)* *Please note: This is a required information for this initiative. This document should be completed for your organization it does not need to be completed for each individual clinician or practice site. Example: ABC Health System has six clinics where 50 clinicians practices. Only one BAA needs to be completed for ABC Health System, its six clinics and 50 clinicians. 1. Please read the entire BAA. 2. On page 1 of the BAA, please enter the date (highlighted in yellow) that you/your practice is signing the document. In addition, please enter the legal name, the doing business name (if applicable) and address of the clinic/group/practice (highlighted in yellow). 3. On page 9, please type the legal name of the clinic/group/practice under the Covered Entity title. 4. Then sign with a physical, handwritten signature (electronic signatures will not be accepted) on the By: line, print your name on the Name: line, print your title on the Title: line, print the date signed on the Date: line, and print the address of the covered entity on the Address: line. 5. The individual who signs this form should have signature authority for the practice (typically, a practice CEO, Administrator or Legal Counsel). 6. Please submit the signed BAA in its entirety to: Ashley Thompson, Compass PTN Initiative Director in one of the following ways: a. thompsona@ihconline.org b. Fax: (515) c. Mail: Iowa Healthcare Collaborative, Attention: Ashley Thompson, 100 E. Grand Avenue, Suite 360, Des Moines, IA Last Updated: 1/6/2016 Page 9 of 9