Iowa Medicaid Enterprise Health Information Technology and Promoting Interoperability Program

Provider Incentive Payment Program

(PIPP) User Manual

Version 3.1

February 2020

February 4, 2020 1

Revision History

Revision

Date

Version

No. Updated By Description of Revision

4/6/2012 1.0 TStanfill Draft

5/30/2012 1.1 TMcAninch / KPeiper

Updates/Corrections throughout manual

7/1/2017 2.0 HWeaver/COrtega Modifications to Meaningful Use in 2017

8/1/2019 3.0 HWeaver Updates/Corrections throughout manual

2/3/2020 3.1 HWeaver Updated Stage 3 Content

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Table of Contents

Contents 1. Preface .............................................................................................................................................. 3

2. Attestation & Registration Process for EP and EH ...................................................... 4 2.1 Registration ....................................................................................................... 4

2.1.1 Access Provider Web Registration .............................................................. 4

2.1.2 Locate Provider Profile .................................................................................. 4 2.1.3 Create New User Name and Password ...................................................... 6

2.1.3.1 Create New User Name ................................................................. 6

2.1.3.2 Create Password ............................................................................ 6

2.1.3.3 Answer Security Questions ............................................................ 7

2.2 Activate Log In User ID ................................................................................... 8 2.3 Log In ................................................................................................................. 9

2.3.1 Provider Dashboard ..................................................................................... 10

2.4 Complete Application ..................................................................................... 11 2.4.1 EP Attestation Information .......................................................................... 11

2.4.1.1 Provider Questions ....................................................................... 12

2.4.1.2 EHR Questions ............................................................................ 16

2.4.1.3 Patient Volume Questions ............................................................ 20

2.4.1.4 Meaningful Use Questions .......................................................... 23

2.4.1.5 Meaningful Use Clinical Quality Measures (CQMs)...................... 36

2.4.2 EH Attestation Information .......................................................................... 39

2.4.2.1 Provider Questions ........................................................................... 40

2.4.2.2 EHR Questions .................................................................................. 41

2.4.2.3 Patient Volume .................................................................................. 44

2.4.2.4 Payment Calculation ........................................................................ 46

2.4.2.5 Meaningful Use Questions & Clinical Quality Measures ............ 48

2.4.2.6 Required Documents for Meaningful Use Measures & CQMs .. 48

2.4.3 Submit Attestation for Review .................................................................... 50

2.5 Recover / Reset Log in Credentials (EP and EH) ..................................... 53 2.5.1 Recover User ID ........................................................................................... 53

2.5.2 Reset Password ........................................................................................... 54 2.5.3 Change Password ........................................................................................ 55

2.6 Upload Supporting / Required Documentation (EP and EH) .................. 56

2.6.1 Add Document .............................................................................................. 56

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1. Preface

This Provider Incentive Program Payment (PIPP) portal user manual is intended to provide Eligible Professionals (EPs) and Eligible Hospitals (EHs) guidelines to successfully navigate the Iowa Medicaid Enterprise (IME) Promoting Interoperability Provider Incentive Payment Program user portal, or PIPP system.

The IME Promoting Interoperability Program is for Medicaid providers eligible for the Medicaid electronic health record (EHR) incentive payments outlined in the American Recovery and Reinvestment Act (ARRA) of 2009. EPs and EHs will use this portal to attest to adoption, implementation or upgrading of a certified Electronic Health Record system and Meaningful Use (MU).

IME is providing this material as a reference to providers. IME will make every reasonable effort to ensure this material is accurate and up-to-date; however it is ultimately the responsibility of the providers to ensure they are submitting the required information in order to receive EHR incentive payments.

Complete definitions and rules can be found in the ARRA, Title XIX of the Social Security Act, the HITECH Act and 42 CFR Parts 412, 413, 422 and 495 Medicare and Medicaid Programs; Electronic Health Record Incentive Program; Final Rule. This guide is not intended to be used in lieu of the Final Rule or any above mentioned Acts for guidelines in qualifying and obtaining EHR incentive payments. Additional program information is available on the CMS Promoting Interoperability website1 and Iowa Department of Human Services Health Information Technology and Promoting Interoperability Program website2. Please refer to the above mentioned Acts, the Final Rules, and websites for more information and clarification.

If you need further assistance, please email the IME Promoting Interoperability Program staff at IMEincentives@dhs.state.ia.us. A member of the staff will respond to your inquiry.

1 CMS Promoting Interoperability website https://www.cms.gov/Regulations-and-

Guidance/Legislation/EHRIncentivePrograms/index.html 2 Iowa DHS HIT and PI Program website https://dhs.iowa.gov/ime/providers/tools-trainings-and-

services/medicaid-initiatives/EHRincentives

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2. Attestation & Registration Process for EP and EH

Prior to gaining access to the IME PIPP portal, EHR registration must be completed within the Centers for Medicare and Medicaid Services (CMS) Registration and Attestation (R&A) website https://ehrincentives.cms.gov/hitech/login.action.

Once IME receives notice from CMS (takes approximately 24 hours) indicating a provider has successfully registered for a Medicaid incentive payment from Iowa, PIPP sends an invitation to register with IME to the email address used during CMS registration.

2.1 Registration

Upon receipt of the email invitation to register in IME PIPP portal, go to https://www.imeincentives.com to create an account.

2.1.1 Access Provider Web Registration

Click on the ‘Provider Web Registration’ link on the left side of the screen.

Figure 1 - Provider Registration

2.1.2 Locate Provider Profile

Enter the required information to locate your provider profile. This information must match the individual or hospital data used to register with CMS R&A.

CMS Registration Number o This is the number received after completing registration within

the CMS Registration and Attestation website. If you have forgotten or lost this number, you can retrieve the number by logging into your CMS Registration and Attestation account. IME does not have this number. If you have forgotten your login information, please contact PECOS External User Services (EUS) at 866-484-8049.

NPI o This is the National Provider Identifier (NPI) you used to register

with CMS. If you are an Eligible Professional, this is your individual NPI.

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Tax ID/Social Security Number o This is the Tax ID you used to register with CMS. If you are an

Eligible Professional, enter your Social Security Number in the Tax ID field.

Click “Find”.

Figure 2 - Create New User 1

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2.1.3 Create New User Name and Password

If you receive an error after entering your information, the system is unable to match the data entered with any active registration data from CMS. Verify the data keyed in. If the data is correct according to your records and the system is still unable to match your registration data, return to the CMS Registration and Attestation website to check your eligibility status and registration data.

Once PIPP validates your provider data, the PIPP portal will prompt you to create a User Name and Password.

The following fields are pre-populated with the data received from CMS. You are responsible for verifying this data is accurate. If any of the pre-populated data is incorrect, you must return to the CMS Registration and Attestation System website to make corrections. IME cannot make corrections to the following information.

CMS Registration Number

NPI

Tax ID

First Name

Last Name

Email Address

NOTE: ALL email correspondence is sent to the email address listed on this screen.

You must enter data in the remaining fields to complete registration. All fields on this screen are required.

2.1.3.1 Create New User Name

The User Name must have the following properties:

Must be between 6 and 10 characters long

May contain a combination of alphanumeric characters

Must NOT contain non-alphanumeric characters

User Name is not case sensitive

2.1.3.2 Create Password

The Password must have the following properties:

Must be between 7 and 10 characters long

Must contain at least one non-alphanumeric character

Must contain at least one upper case character

Must contain at least one lower case character

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2.1.3.3 Answer Security Questions

Security questions are used in the event the User Name and/or Password needs to be recovered or reset.

Figure 3 - Create New User 2

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2.2 Activate Log In User ID

Once you create your account, PIPP sends an activation email to the email address registered with the CMS R&A system.

Click on the link provided to activate your account. You must click on the link to activate your account in order to be granted access to the PIPP portal.

Figure 4 - Activation Email

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2.3 Log In

When you click on the link provided in the activation email, you will be directed to the IME PIPP portal Log In screen.

Enter the User Name and Password created during IME PIPP portal registration to begin your application for an IME EHR incentive payment.

Figure 5 - Log in Screen

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2.3.1 Provider Dashboard

The main provider screen (Provider Dashboard) displays any email communications sent to the email address registered with the CMS Registration and Attestation system, as well as the status of your attestation, payment history (if applicable) and additional guidelines for completing your application.

The following table describes the possible statuses of your application:

Status Description

CMS Received Notification EHR registration has been received from CMS.

Application Pending Application process has begun, but is not yet submitted to IME.

Application Returned Provider application is incomplete and has an item or items missing. An email communication will be sent to the email on file communicating what is needed for resubmission.

You will need to correct or include any requested information and re-confirm all question pages.

Application Review Provider Application is complete – Submitted for Review.

Application Review Secondary

Application is in the second phase of the review process.

Application Review Supervisor

Application is in the third phase of the review process.

Pending CMS Review IME review complete – awaiting approval from CMS to release payment.

Ready for Payment Notification of CMS approval for payment received by IME.

Payment Pending Payment being processed by IME.

Payment Complete Payment issued by IME.

Payment Rejected by CMS

Notification of CMS payment rejection received by IME.

Application Denied Application is denied by IME.

Cancelled by CMS Registration is INACTIVE at CMS – the State was notified by CMS that the provider registration has been inactivated. The provider will need to contact CMS.

Table 1 - Application Statuses

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2.4 Complete Application

On the left side of the Provider Dashboard screen, click on the ‘Apply for Incentive (Attest)’ link.

Figure 6 - Apply for Incentive (Attest)

2.4.1 EP Attestation Information

Clicking on ‘Apply for Incentive (Attest)’ link will display the Provider Attestation screen.

The “Provider EHR Criteria” section displays the attestation question pages that must be completed. Begin your application by selecting the Provider Questions ‘Attest’ link. You must respond to all of the questions on each page. Once you have answered the questions on a page, click “OK”, if no errors are received your data is saved and you will be returned to the Provider Attestation main page to select another question page. If errors are displayed, you must correct any errors before your data is saved. You have the ability to change your answers on any page up until your application is submitted for review.

Figure 7 - EP Provider Attestation

Each criteria page must be completed successfully, status is “Attest,” to submit an application for an incentive payment.

Criteria:

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Provider Questions – General questions used to determine incentive payment eligibility.

EHR Questions – Questions specific to the certified EHR system/module(s) you use.

Patient Volume – Questions specific to the Medicaid patient volume requirement of the program.

Meaningful Use Questions – Meaningful Use objectives and measures outcome reporting.

Meaningful Use Clinical Quality Measures – Clinical quality measures outcome reporting.

Status:

Pending – Answers have not been confirmed or saved.

Attested – Answers have been confirmed or saved.

Pass – Question page has been approved in one or more of the IME review processes.

Fail – Question page has been denied in one or more of the IME review processes.

Received Date – Date of the latest status change.

Denial Reason – Return and denial reasons are displayed in this column.

Attested? – “No” will change to “Yes” as you complete each page.

2.4.1.1 Provider Questions

Are you currently enrolled as an Iowa Medicaid provider? o Yes o No - You will be required to agree to an additional set of

terms and conditions prior to your application being reviewed.

My professional license number is: o Enter your state-issued professional license number.

Do you have any sanctions pending or imposed against you? o Yes – A text box is displayed for you to enter a brief

description of the sanction(s). The description is limited to 100 characters. Please upload any necessary supporting documentation or comments.

o No

What is the NPI of the organization for which you bill? o Please enter your organization’s Billing NPI.

Hospital-based EPs are not eligible for the incentive payment. Are you a hospital-based provider?

o Yes – You cannot be hospital-based and qualify for an EHR incentive payment. An EP is defined as being hospital-based, and therefore ineligible to receive EHR incentive payments under either Medicare or Medicaid,

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regardless of the type of service provided, if 90 % or more of their services are identified as being furnished under place of service codes 21 (Inpatient Hospital) or 23 (Emergency Room, Hospital). This exclusion does not apply to Medicaid EPs qualifying based on practicing predominantly at a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC).

o No

Are you a Pediatrician? o The Iowa Medicaid Promoting Interoperability Program

definition of Pediatrician is: A physician who is board-certified in pediatrics by the American Board of Pediatrics or the American Osteopathic Board of Pediatrics. Note: ARNPs working primarily in a pediatric setting are not considered pediatricians.

o Yes – The patient volume threshold for pediatricians is 20%. Pediatricians that have at least 20% Medicaid patient volume but less than 30% will receive a reduced incentive payment. If a pediatrician reports patient volume equal to or over 30%, the pediatrician will receive the full incentive payment.

o No

Physician Assistants (PA) only: Do you practice predominantly in an FQHC/RHC?

o EPs that practice predominantly in an FQHC or RHC are not subject to being excluded as Hospital-Based EPs and are able to use the Needy Individual population to meet their patient volume threshold of 30%. An EP “practices predominantly” at an FQHC or RHC when the clinical location for over 50 percent of his or her total patient encounters over a period of 6 months in the most recent calendar year occurs at an FQHC or RHC.

o No

For a PA to be eligible to participate in the program he or she must practice in a federally qualified health center or a rural health clinic when the PA is the primary provider, clinical or medical director, or owner of the site.

o How is your clinic ‘so led’ by a PA?

For FQHCs

PA is the Director of the Clinic

PA is the Primary Provider

For RHCs

PA is the Director of the Clinic

PA is the Owner of the Clinic

PA is the Primary Provider of the Clinic o You will be required to provide additional information to

demonstrate the FQHC or RHC is ‘so led’ by a PA.

Are you attesting to patient volume at a group or individual level?

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o Group – Select either By Group Payee Tax ID, By Group NPI, or By Group Physical Location.

Define Group: How is your Group defined?

Select By Group Payee Tax ID.

The Payee Tax ID used during your CMS registration will populate.

You will be required to attach documentation listing the names and billing NPIs of the facility/clinic or providers associated with the Group Payee Tax ID during the patient volume reporting period.

You have indicated you are attesting at the group level using the Payee Tax ID used during your CMS registration to define your group. Are you sure Payee Tax ID is the group definition you want to use?

Yes

Cancel – reselect your Group definition.

Define Group: How is your Group defined?

Select By Group NPI.

Select NPI from dropdown if available.

Enter the Group NPI.

Re-enter the Group NPI.

You have indicated you are attesting at the group level using NPI to define your group. Are you sure NPI is the group definition you want to use?

Yes

Cancel – reselect your Group definition.

Define Group: How is your Group defined?

Select By Group Physical Location.

Enter your Group Physical location or select it from the dropdown if available.

For all providers attesting using the same Group Physical location, the address must be entered exactly the same for each attestation.

You have indicated you are attesting at the group level using Physical Location to define your group. Are you sure Physical Location is the group definition you want to use?

Yes

Cancel – reselect your Group definition.

You will be required to attach documentation listing the individual provider names and NPIs that practiced at the Group Physical location during the patient volume reporting period.

o Individual

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For Physician Assistants, Certified Nurse Midwives and Nurse Practitioners Only: Are you currently seeing Medicaid patients billed through a supervising physician?

o Yes – Supervising physician’s NPI is required. o No

Do you practice in multiple locations? o Yes – Click on “Add Location” to enter the addresses of all

locations where you provide services. You are required to enter at least two addresses. This information will populate the “Meaningful Use Questions” screen.

o No

Enter the primary or alternate contact’s email address for the attestation.

Upload supporting documentation. o License Verification o Group Definition o Proof of PA Clinic o Proof of PA Director o Proof of PA Ownership o Proof of PA Primary o Sanctions Detail o Other

Figure 8 - EP Provider Questions 1

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Figure 9 - EP Provider Questions 2

2.4.1.2 EHR Questions

Have you adopted, implemented or upgraded to certified electronic health record (EHR) technology?

o Yes o No – In order to attest, you must have adopted,

implemented or upgraded to certified electronic health record technology.

CMS EHR Certification number: o If you included your EHR Certification number in your CMS

registration, this field is pre-populated with that number. Please verify this number is accurate and correct if needed.

o If you did not include your EHR Certification number in your CMS registration you must enter this number here. A valid EHR Certification number is required on this page.

The CMS EHR Certification number used in previous years will not be displayed; you will need to enter your EHR Certification number.

A valid EHR Certification number must be entered.

Name, version, and description of Certified EHR System: o Enter the name, version and a brief description of your

Certified EHR technology in the text box provided. The text box is limited to 100 characters. If more space is needed please attach a document with additional details.

Attest to Supporting Health Care Providers with the Performance of Certified EHR Technology (SPPC).

o You must attest that:

(i) I acknowledge the requirement to cooperate in good faith with the ONC direct review of CEHRT,

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(ii) If requested I will permit access to such technology and demonstrate its capabilities as implemented and used in the field.

o You may optionally attest that:

(i) I acknowledge the option to cooperate in good faith with the ONC-ACB surveillance of CEHRT and,

(ii) If requested I will permit timely access to such technology and demonstrate its capabilities as implemented and used in the field.

The Final Rule also updates the definition of Meaningful Use to include support for health information exchange and the prevention of information blocking. For the EHR reporting period you must attest to the following:

I did not knowingly or willfully take action to limit or restrict the compatibility or interoperability of the CEHRT.

The CEHRT, at all relevant times, (i) was connected in accordance with applicable law, (ii) compliant with all standards applicable to the exchange of information, (iii) allowed for timely access by patients to their electronic health information, and (iv) allowed for the timely, secure, and trusted bi-directional exchange of structured electronic health information with other health care providers, and other CEHRT technology and vendors.

I responded in good faith and in a timely manner to requests to retrieve or exchange electronic health information.

Yes

No- you must select “yes” in order to continue with the application.

This section only appears for programs years 2017 and 2018 and if you entered a 2015 CMS Certification number (e.g. 0015EDZ8S2Q0QEJ). The system has determined you are using a 2015 Edition CEHRT or a 2015 Hybrid Edition of CEHRT (that is, a combination of the 2014 and 2015 Editions of CEHRT).

o For Program Years 2017 and 2018 Only:

A provider who has technology certified to the 2015 Edition may attest to:

The modified Stage 2 requirements; or

Stage 3 requirements

A provider who has technology certified to a combination of 2015 Edition and 2014 Edition may attest to:

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The modified Stage 2 requirements; or

The Stage 3 requirements if the mix of certified technologies does not prohibit the provider from meeting the Stage 3 objectives and measures.

Please select the stage to which you will attest for the current program year:

You will be required to select either “Modified Stage 2” or “Stage 3”. Your selection will determine the stage of meaningful use you will be attesting to in the “Meaningful Use Questions” section.

o For Program Years 2019 and beyond the 2015 Edition CEHRT is required.

You are required to upload at least one supporting document: o Vendor Letter o Receipt o Contract

All information listed below must be included in your documentation:

o Vendor name o Product Version o Facility name and address o Signature(s) o Date showing the required CEHRT Edition was used

during the EHR reporting period.

Figure 10 - EP EHR Questions (Program Year 2018)

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Figure 11 - EP EHR Questions (Program Years 2019 and beyond)

Figure 12 - EP EHR Questions - Final Rule Updates

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Figure 13 - EP EHR Questions – Final Rule Updates

Figure 14 - EP EHR Questions – MU Stage Selection (Only appears for Program Years 2017 & 2018)

2.4.1.3 Patient Volume Questions

If you are applying during the 60-day grace period following the end of the incentive year, you will be required to identify the incentive year you are applying for.

Select the beginning date for the 90-day period you are using to meet the patient volume requirement. For EPs this period must be in the preceding calendar year. The end date of the 90-day qualifying period is auto-calculated for you.

o Begin Date – mm/dd/yyyy o End Date – mm/dd/yyyy (auto-calculated)

What is the total number of patient encounters within the selected 90-day period? (e.g. your denominator)

o Enter the TOTAL patient encounter count for the selected 90-day period.

What is the total number of enrolled Medicaid encounters for the selected 90-day period? (e.g. your numerator)

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o Enter the TOTAL enrolled Medicaid encounter count (includes Needy Individual count if applicable) for the 90-day period.

Percentage of enrolled Medicaid encounters over the selected 90-day period:

o This percentage is automatically calculated using the numerator and denominator entered above.

Are any of your Medicaid patients covered by another state’s Medicaid program?

o Yes – A table displays to enter additional data. Enter the state abbreviation and the encounter count for that state.

To ensure accurate multi-state reporting Iowa Medicaid encounters must also be reported in this table. IA is the default for your first entry.

o No

Do you meet the definition of Practices Predominantly? o Yes o No

Does your 30% Patient Volume encounters include Needy Individuals? o This question displays only if you answered that you practice

predominantly in an FQHC or RHC. o Yes – Enter the following counts:

IME Medicaid Hawki/CHIP Uncompensated No Cost or reduced Cost

o No

What is the auditable data source you are using to calculate patient volume?

o EHR Report o Billing system o Appointment Book o Other – provide a brief description of the “other” source

Are you including inpatient encounters in your patient volume? o Yes o No

Are you including patients for whom you did not have encounter in the 90-day period from your patient panel (but for whom you did see in the previous 24 months) in your numerator?

o Yes – The count of MediPASS patients is required o No

Are you including patient encounters where Medicaid had no liability to pay?

o Yes- Enter the following: Zero paid Denied Unbilled

o No

Upload supporting documentation: Proof of Patient Volume (required)

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Proof of Practice Predominantly in FQHC/RHC Zero-Paid or Unbilled Claim Info Other – Please specify

Figure 15 - EP Patient Volume

Figure 16 - EP Patient Volume - Other State(s)

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Figure 17 - EP Patient Volume - Needy Individuals

Figure 18 - EP Patient Volume – Data Source, Inpatient, MediPASS panel and no liability to pay

2.4.1.4 Meaningful Use Questions

Instructions:

Attach supporting Meaningful Use attestation documentation (e.g. MU dashboard, Security Risk Assessment, etc.) by clicking the “Add Document” button. This button is located at the top and bottom of the page.

Depending on the attestation stage selected in the EHR Questions section either Stage 2 or Stage 3 will display.

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Figure 19 - EP Meaningful Use: Add document

General Questions: Note: additional “GEN” boxes will appear if you answered “yes” to practicing at multiple locations in the “Provider Question section”.

GEN-1: Enter your selected Reporting Period:

Figure 20 - EP Meaningful Use: EHR Reporting Period

GEN-2: To be a meaningful user, at least 80% of unique patients must have their data in the certified EHR during the EHR reporting period.

Figure 21 - EP Meaningful Use: General 80% Question

GEN-3: You must select the principal county in which you practice.

Figure 22 - EP Meaningful Use: Principal County

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GEN-4: You must select the specialty that best describes your individual scope of practice.

o Note: this question does not appear for Provider Types: Certified Nurse Midwife (CNM) Physician Assistant (PA) Dentist

Figure 23 - EP Meaningful Use: Provider Specialty

EP Objectives:

Attestation for most objectives is accomplished by entering a numerator, denominator and exclusion information. Certain objectives do not require a numerator and denominator, but rather a Yes/No answer. Objectives that require the denominator type will display the types of denominators allowed, you must select a denominator source. All questions require an answer unless otherwise specified.

All Meaningful Use objectives are displayed in a similar fashion. Review the section below prior to beginning attestation to become familiar with the MU questions.

Due to the nature of the program, not all of the MU objectives and associated measures are described in detail in this manual. The objectives and measures may change according to new federal regulations, and will change depending on the stage of MU you are attesting to. Please refer to the final rule www.cms.hhs.gov/EHRincentiveprograms for detailed information on the Meaningful Use objectives and measures.

Objectives, Measures, and Answers:

The left column displays the objective number and title from 42 CFR § 495 to allow you to easily locate the objective in the final rule for any clarifications you may need. The rows associated with each objective display the objective description, measure(s), exclusion(s), numerators, denominators, and Yes/No where applicable; and any other instructions.

Denominator Type:

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For objectives with measures that require the type of denominator you used to produce your MU data, a section displays to indicate the source of your denominator.

Figure 24 - EP Meaningful Use: Denominator Source

Modified Stage 2 Objectives and Measures:

Figure 25 - EP Stage 2 Meaningful Use: Protect Patient Health Information

Figure 26 - EP Stage 2 Meaningful Use: Clinical Decision Support

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Figure 27 - EP Stage 2 Meaningful Use: Computerized Provider Order Entry (CPOE)

Figure 28- EP Stage 2 Meaningful Use: Electronic Prescribing

Figure 29 - EP Stage 2 Meaningful Use: Health Information Exchange

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Figure 30 - EP Stage 2 Meaningful Use: Patient Specific Education

Figure 31 - EP Stage 2 Meaningful Use: Medication Reconciliation

Figure 32 - EP Stage 2 Meaningful Use: Patient Electronic Access (VDT)

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Figure 33 – EP Stage 2 Meaningful Use: Secure Messaging

Figure 34 - EP Stage 2 Meaningful Use: Measure 1- Immunization Registry

Figure 35 - EP Stage 2 Meaningful Use: Measure 2- Syndromic Surveillance

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Figure 36 - EP Stage 2 Meaningful Use: Measure 3- Specialized Registry

Stage 3 Objectives and Measures: Required for Program Years 2019 and beyond

Figure 37 - EP Stage 3 Meaningful Use: Protect Patient Health Information

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Figure 38 - EP Stage 3 Meaningful Use: Electronic Prescribing

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Figure 39 - EP Stage 3 Meaningful Use: Clinical Decision Support

Figure 40 - EP Stage 3 Meaningful Use: Computerized Provider Order Entry (CPOE)

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Figure 41 - EP Stage 3 Meaningful Use: Provide Patient Access (Timely Access) & Patient Specific Education

Figure 42 - Stage 3 EP Meaningful Use: View, Download or Transit (VDT), Secure Messaging, & Patient Generated Health Data

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Figure 43 - EP Stage 3 Meaningful Use: Summary of Care & Clinical Information Reconciliation

Figure 44 - EP Stage 3 Meaningful Use: Measure 1- Immunization Registry

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Figure 45 - EP Stage 3 Meaningful Use: Measure 2 - Syndromic Surveillance

Figure 46 - EP Stage 3 Meaningful Use: Measure 3 – Electronic Case Reporting

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Figure 47 - EP Stage 3 Meaningful Use: Measure 4 - Public Health Registry

Figure 48- EP Stage 3 Meaningful Use: Measure 5 - Clinical Data Registry

2.4.1.5 Meaningful Use Clinical Quality Measures (CQMs)

Select the electronic clinical quality measures (eCQMs) that best fit your practice and/or patient population. The full list of available eCQMs can be found on the electronic Clinical Quality Improvement (eCQI) Resource Center website https://ecqi.healthit.gov/eligible-professional/eligible-clinician-ecqms?field_year_value=1.

Choose one of the following:

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o Adult Patient Population o Pediatrician Patient Population o Manual Selection

A minimum of 6 eCQMs must be selected

Figure 49 - EP Adult, Pediatric Recommended and All eCQMs Filters

Enter your eCQM reporting period.

Figure 50 – EP eCQMs Reporting Period

The measure Performance Rate will auto-calculate once data is entered in the numerator, denominator, exclusion, and exception fields.

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Figure 51 - EP eCQM data fields

Attach supporting eCQM documentation by clicking the “Add Document” button located at the bottom of the page.

Figure 52 - EP eCQMs- Add document

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You are now ready to submit your attestation. Refer to the “Submit Attestation for Review” section.

2.4.2 EH Attestation Information

Clicking on ‘Apply for Incentive (Attest)’ link displays the Provider Attestation screen.

The “Provider EHR Criteria” section displays the attestation question pages that must be completed. Begin your application by selecting one of the ‘Attest’ links. You must respond to all of the questions on each page. Once you have answered the questions on a page, click “OK”. If no errors are received your data is saved and you will be returned to the Provider Attestation main page to select another question page. If errors are displayed, you must correct any errors before your data is saved. You have the ability to change your answers on any page up until your application is submitted for review.

Figure 53 - EH Attestation Page

Each page must be completed successfully to submit an application for an incentive payment.

Criteria:

Provider Questions – General questions used to determine incentive payment eligibility

EHR Questions – Questions specific to the certified EHR system/module(s) you use

Patient Volume Questions – Questions specific to the Medicaid patient volume requirement of the program

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Payment Calculations – Calculator used to calculate the incentive payments

Required Documents for Meaningful Use Measures and CQMs

Status:

Pending – Answers have not been confirmed or saved

Attested – Answers have been confirmed or saved

Pass – Question page has been approved in one or more of the IME review processes

Fail – Question page has been denied in one or more of the IME review processes

Received Date – Date of the latest status change

Denial Reason – Return and denial reasons are displayed in this column

Attested? – “No” will change to “Yes” as you complete each page.

2.4.2.1 Provider Questions

Type of hospital? o Critical Access Hospital (CAH) o Acute Care Hospital

Does the hospital have any sanctions pending? o Yes - A text box is displayed for you to enter a brief

description of the sanction(s). The description is limited to 100 characters. Please upload any necessary supporting documentation or comments.

o No

Is the hospital’s average patient length of stay less than 25 days? o Yes o No – To be eligible for incentive payments a hospital’s

average length of stay must be 25 days or less. Please check your figures before continuing with the data input.

Upload supporting documentation o Sanctions Details o Proof of Average Length of Patient Stay o Other

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Figure 54 - EH Provider Questions

2.4.2.2 EHR Questions

Has the hospital adopted, implemented or upgraded to certified electronic health record (EHR) technology?

o Yes o No - In order to attest, the hospital must have adopted,

implemented or upgraded to certified electronic health record technology

The hospital’s CMS EHR Certification number: o The CMS EHR Certification number entered in your

Hospital Medicare Promoting Interoperability Program attestation will populate here.

Name, version, and description of Certified EHR System: o Enter the name, version and a brief description of your

Certified EHR technology in the text box provided. The text box is limited to 100 characters. If more space is needed please attach a document with additional details.

Attest to Supporting Health Care Providers with the Performance of Certified EHR Technology (SPPC).

o You must attest that:

(i) I acknowledge the requirement to cooperate in good faith with the ONC direct review of CEHRT,

(ii) If requested I will permit access to such technology and demonstrate its capabilities as implemented and used in the field.

o You may optionally attest that:

(i) I acknowledge the option to cooperate in good faith with the ONC-ACB surveillance of CEHRT and,

(ii) If requested I will permit timely access to such technology and demonstrate its capabilities as implemented and used in the field.

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The Final Rule also updates the definition of Meaningful Use to include support for health information exchange and the prevention of information blocking. For the EHR reporting period you must attest to the following:

I did not knowingly or willfully take action to limit or restrict the compatibility or interoperability of the CEHRT.

The CEHRT, at all relevant times, (i) was connected in accordance with applicable law, (ii) compliant with all standards applicable to the exchange of information, (iii) allowed for timely access by patients to their electronic health information, and (iv) allowed for the timely, secure, and trusted bi-directional exchange of structured electronic health information with other health care providers, and other CEHRT technology and vendors.

I responded in good faith and in a timely manner to requests to retrieve or exchange electronic health information.

Yes

No- you must select “yes” in order to continue with attestation.

Have you attested with Medicare for a meaningful use payment? o Yes – Please provide the Payment Year for the Medicare

incentive o No

You are required to upload at least one supporting document: o Vendor Letter o Receipt o Contract

All information listed below must be included in your documentation:

o Vendor name o Product Version o Facility name and address o Signature(s) o Date showing the required CEHRT Edition was used

during the reporting period.

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Figure 55 - EH EHR Questions 1

Figure 56 - EH EHR Questions 2

Figure 57 - EH EHR Questions 3

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2.4.2.3 Patient Volume

What is your hospital’s fiscal year end date? o End Date – mm/dd/yyyy

Select the beginning date for the 90-day Patient Volume period in the previous Hospital Fiscal Year that ended during the previous Federal Fiscal Year.

o The end date is auto-calculated. o All eligible hospitals except Children’s Hospitals must meet the

Medicaid Patient Volume threshold of 10% Children’s Hospitals do not have a patient volume

threshold requirement; therefore, they are not required to complete this section.

o Begin Date – mm/dd/yyyy o End Date – mm/dd/yyyy (auto-calculated)

What is the total number of patient encounters within the selected 90-day qualifying period? (e.g. your denominator)

o Enter the TOTAL patient encounter count for the selected 90-day qualifying period.

o For the purpose of calculating Patient Volume, the total patient encounters is the total population regardless of payment source where:

Services rendered to an individual per inpatient discharge; or

Services rendered to an individual in an emergency department on any one day

What is the total number of enrolled Medicaid encounters for the selected 90-day qualifying period? (e.g. your numerator)

o Enter the TOTAL enrolled Medicaid encounter count for the 90-day qualifying period.

o For the purpose of calculating Patient Volume, a Medicaid encounter is defined as:

Services rendered to an individual per inpatient discharge where Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid for part or all of the service; or

Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid all or part of the individual’s premiums, co-payments and/or cost-sharing; and

Services rendered to an individual in an emergency department on any one day where Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid for part or all of the service; or

Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid all or part of the individual’s premiums, co-payments and/or cost-sharing.

Percentage of enrolled Medicaid encounters over the selected 90-day qualifying period:

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o This percentage is automatically calculated using the numerator and denominator information entered above.

Are any of the hospital’s Medicaid patients covered by another state’s Medicaid program?

o Yes – A table is displayed to enter additional data. The state abbreviation and the encounter count for that state may be entered.

To ensure accurate multi-state reporting Iowa Medicaid encounters must also be reported in this table. IA is the default for your first entry.

o No

What is the auditable data source you are using to calculate patient volume?

o EHR Report o Billing system o Appointment Book o Other – provide a brief description of the “other” source

Are you including patient encounters where Medicaid has no liability to pay?

o Yes- Enter the following: Zero paid Denied Unbilled

o No

Upload supporting documentation: o Proof of Patient Volume (required) o Zero-Paid or Unbilled Claim Info o Other – Please specify

NOTE: Do NOT include patient medical records as documentation.

Figure 58 - EH Patient Volume

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Figure 59 - EH Patient Volume - Other State(s)

Figure 60 – EH Patient Volume- Medicaid No Liability to Pay

2.4.2.4 Payment Calculation

Data entered in this screen is used to calculate the hospital incentive payment amounts.

Hospitals can use any auditable data source for calculating the incentive payment. References to the Medicare cost report are included in each section for guidance.

Critical access hospitals may use an independent auditors report for proof of charity care, minus bad debt.

Indicate the auditable data source you are using and attach supporting documentation:

o JAR o CMS Hospital Cost Report o Both

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Overall EHR Amount: o Current Year Discharges o Prior Year 1 (Discharges) o Prior Year 2 (Discharges) o Prior Year 3 (Discharges) o Click “COMPUTE”

Medicaid Computation: o Total Medicaid Days – Number of inpatient-bed-days attributable

to Medicaid and Medicaid Managed Care o Total Medicaid HMO Days o Total Hospital Charges o Other Uncompensated Care Charges (aka Charity Charges) o Total Hospital Days o Click “COMPUTE”

Are you including patients also covered by Medicare Part A or Medicare Advantage in your total Medicaid days?

o Yes o No

Upload supporting documentation: o Proof of hospital calculator data

Required if the auditable source selected above is “Other” or “Both”

Figure 61 - EH Payment Calculator 1

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Figure 62 - EH Payment Calculator 2

2.4.2.5 Meaningful Use Questions & Clinical Quality Measures

Medicare will forward dually eligible hospital meaningful use and electronic clinical quality measures (eCQMs) data to IME. Once the data is received an email notification will be sent prompting you to log into the PIPP portal to attest to the Medicaid requirements. You must meet the Medicaid requirements every year to qualify for Medicaid EHR incentive payments.

When you log in to the system to apply for your Medicaid EHR incentive payment, your meaningful use screens will be set to “Pass”.

Figure 63 – EH Meaningful Use and Attestation Pages

2.4.2.6 Required Documents for Meaningful Use Measures & CQMs

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Meaningful Use attestation information will need to be entered in this screen. Documentation to support your meaningful use objectives and electronic clinical quality measures attestation will also need to be attached to this screen.

Upload supporting documentation: o CEHRT Dashboard o CQM report o SRA Document o Public Health/Clinical Data Registry Support o Other – Please specify

Note: Answers to sections “Did you attest to meeting this measure” and “Level of Engagement” sections of the Public Health and Clinical Data Registry Reporting objective will share over from your Medicare attestation.

Figure 64 – EH Required Meaningful Use and Clinical Quality Measures 1

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Figure 65 – EH Required Meaningful Use and Clinical Quality Measures 2

2.4.3 Submit Attestation for Review (EP and EH)

Once all Attestation links have been completed, the “Attested?” column on the far right will display “Yes” for all rows.

When you complete all attestation pages, “Submit for Review” is displayed. After clicking that button, a page is displayed requiring you to agree or disagree with the statements listed in the box. Please read the text thoroughly and select the appropriate statement. If you click “I Do Not Agree,” your attestation will not be submitted. Clicking on “I Agree” submits your information to IME for review.

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Figure 66 - Submit for Review and Agree

If you are not currently enrolled to bill as an Iowa Medicaid provider an additional page displays requiring you to either agree or disagree with the statements listed. Please read the text thoroughly and select the appropriate statement. If you click “Do Not Agree,” your attestation will not be submitted. Clicking on “Agree” submits your information to IME for review.

Figure 67 – Additional Submit for Review and Agree – Not Enrolled to Bill Another pop-up box will appear indicating that your information has been successfully submitted. Click on “Log Out” (upper left hand side) and you are done!

Figure 68 - Acknowledging Attestation Complete

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If at any time you want to see the status of your attestation, return to the portal, log in, and the latest information will be available to you. You also have the ability to print your application questions and answers on the Provider Attestation page.

Following submission, the first column will disappear (Attest link) preventing any changes to your application. If IME discovers a problem or requires additional information, your application will be returned for you to make changes.

Figure 69 - Print Application

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2.5 Recover / Reset Log in Credentials (EP and EH)

In the event you need to recover your User Name or reset your Password, please follow these steps:

2.5.1 Recover User ID

Click on ‘Recover User ID’ link from the Log In page.

Enter the following information: o CMS Registration Number (NLR#) o NPI o Tax ID

An email with your User Name will be sent to the email address on file in the CMS R&A system.

Figure 70 - Recover User ID link

Figure 71 - Recover User ID

Figure 72 - Recover User ID Email

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2.5.2 Reset Password

Click on ‘Reset Password’ link from the Log In page.

Enter the following information: o User Name o Click Next

Select appropriate security question o You must provide a correct response to one of the three

questions you answered when creating your User Name o Click Next

You will be taken to a screen to create a new password

Enter the new password

Confirm the new password o The new password must be different from your previous

passwords o Also note you will need to use the same guidelines you used

when creating your initial password: Between 7 and 10 characters Must contain at least one non-alphanumeric character

(symbol) Must contain at least one upper case character Must contain at least one lower case character

Click “Save”

You are now able to log in to the system using your newly created password.

Figure 73 - Reset Password Link

Figure 74 - Reset Password

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Figure 75 - Create New Password

2.5.3 Change Password

Follow the steps below to change your password.

Log in

Click on “My Profile” on the left of the Dashboard

Enter your old password

Enter and Confirm your new password

Answer security question

Click “Save”

Figure 76 - My Profile - Change Password

Figure 77 - My Profile – Change Password Confirmation

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2.6 Upload Supporting / Required Documentation (EP and EH)

All Attestation screens in the IME PIPP portal allow for the upload of supporting documentation. Some screens require supporting documentation to be uploaded. Please follow the steps below to upload your documentation wherever applicable. Do NOT include patient medical records as documentation. For proof of EHR documentation, do NOT send a copy of the entire contract or lease.

NOTE: For security purposes the uploaded documents are limited to the following file types:

Excel - .xls, .xlsx

Word - .doc, .docx, .rft

Power Point - .ppt

Text - .txt

PDF - .pdf

Images - .jpg, .jpeg, .gif, .png, .bmp, .tiff

2.6.1 Add Document

1. Click “Add Document” 2. Click on Document Name drop down box to select your document type

o This drop down box will vary depending on the Attestation screen to which you are uploading.

3. Click “Browse” o Select file to be uploaded then click “Open” o Click “Upload File”

4. Once the file is done uploading and the selected file name appears in the “Document Name” field – Click “OK”

o To remove the attached document – Click “Remove” o To view the document – Click “View”

5. Repeat steps 1 through 4 to upload additional documents.

NOTE: The current file size limit is 10MB. Do NOT include patient medical records as documentation.

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Figure 78 - Add Document

Figure 79 - Add Document - Select Document Name

February 4, 2020 58

Figure 80 - Add Document - Select File

Figure 81 - Add Document - Confirm