Promoting Interoperability (PI) Program
The Centers for Medicare & Medicaid (CMS) announced the renaming of the Medicare & Medicaid EHR Incentive Programs to Promoting Interoperability Programs. This name change is intended to reflect the programs’ focus on improving interoperability and patients’ access to health information.
The PI program was established by the Health Information Technology for Economic and Clinical Health (HITECH) Act of the American Recovery & Reinvestment Act of 2009. The program aims to transform the nation’s health care system and improve the quality, safety and efficiency of patient health care through the use of electronic health records.
In 2011, CMS established the Medicare and Medicaid EHR Incentive Programs to encourage Eligible Professionals (EPs), Eligible Hospitals, and CAHs to adopt, implement, upgrade (AIU), and demonstrate meaningful use of certified EHR technology (CEHRT).
In 2021, Eligible Hospitals and Eligible Professionals (EPs) that attest directly to a state for the state’s Medicaid Promoting Interoperability (PI) Program will continue to attest to the measures and objectives as finalized in the 2015 EHR Incentive Programs Final Rule (80 FR 62762 through 62955). The last year new EPs were able to enter the program for the first time was 2016.
If you have any questions regarding the attestation process, please call our helpline at 855-716-9376 or email CTMedicaidPI@mslc.com.
Change Registration Information Here
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User Manual for Eligible Professionals
2020 and 2021 Program Requirements
Eligible Professionals 2020 and 2021 Stage 3 Program requirements
Important Contact Information
Myers and Stauffer LLC
7 Waterside Crossing, Suite 202
Windsor, CT 06095
Required Supporting Documentation for Attestation in the PI Program
In this section you will find a checklist of supporting documentation information for attestation to the Medicaid PI Program. Please read all of the points to find notes on what is required to pass the review process. You can download a printable version of this checklist for your convenience.
Patient Encounter List (PEL)
- This needs to be in an Excel file format, and should be completed using the PEL Template.
- To use the template you will need to download the file and save as PEL_Last Name.xlsx
- Please make sure to read the PEL template instructions tab in its entirety before proceeding to the PEL template tab
- The dates of service in the file must be within the 90 day Patient Volume reporting period.
- The file must include all patient encounters that occurred during the 90 day period. A patient encounter is defined as any encounter where a medical treatment is provided or evaluation and management services are provided.
- There must be a column for each of these exact headers:
- Date of Service
- Patient First Name
- Patient Last Name
- Date of Birth
- Medicaid ID (when applicable)
- Payer (insurance name or self-paid)
- Service Provider NPI
- Duplicates need to be removed. You can use the formula provided in the template above to find any duplicates.
- The Patient Volume percentage (total Medicaid patients/total patients) must be 30% or above (or 20% or above for pediatricians).
- Documentation supporting the use of the appropriate version of the EHR.
- It should indicate agreement between the provider/practice and the vendor of the EHR system.
- There should be a total purchase price on the document (redacted is acceptable).
- If the EHR system is free, there should be a letter from the vendor indicating this.
Completed Security Risk Assessment (SRA)
- For 2021, please upload one of the following:
- A security risk analysis completed by staff at the facility. This must be in line with the guidelines set by the state. For more information, please see the Security Risk Analysis presentation, CMS tip sheet, or Myers and Stauffer tip sheet below.
- A security risk analysis as outlined on the ONC website using this tool. This is only a tool, and should not be interpreted as a complete SRA.
- The Security Risk Analysis that is required is the full comprehensive report, including all the guidelines within. This is the document that you based the checklist off of. The SRA checklist will not be accepted as a substitute for your SRA.
- The SRA may be completed after submitting your 2021 attestation. However, the completed SRA will need to be uploaded to MAPIR by December 31, 2021.
- You can confirm your EHR technology is certified and find the CEHRT/Cart Page here: ONC Certified Health IT Product List (CHPL).
- In Program Year 2021, all Eligible Professionals are required to use technology certified to the 2015 Edition. The 2015 Edition CEHRT did not have to be implemented on January 1, 2021. However, the functionality must be in place by the first day of the EHR reporting period and the product must be certified to the 2015 Edition criteria by the last day of the EHR reporting period.
- It must contain the Product Certification Number, Product Name, and Vendor Name.
- Make sure the CEHRT ID you entered in MAPIR matches the one on this page.
- Below is an example of what the Cart Page should look like. You can find instructions for the website here.
Meaningful Use Documentation
MU and CQM CEHRT Reports (Dashboards)
- These must be clearly generated from your EHR technology and they must be legible. Excel spreadsheets will not be accepted.
- You should have at least one document for the Objectives and at least one document for the Clinical Quality Measures.
- Each document should contain the Provider Name, Name Identifier, or NPI. It should also contain Measure Identifiers, and a 90-day Meaningful Use period matched to the one entered in MAPIR.
- You must attest to 6 Clinical Quality Measures. EPs are required to report on at least once outcome measure. If no outcome measures are relevant to that EP, they must report on at least one high-priority measure. If there are no outcome or high priority measures relevant to an EP’s scope of practice, they must report on any six relevant measures.
The Connecticut Promoting Interoperability Program no longer supports the Electronic Clinical Quality Measures (eCQM) option.
Objective 8 Supporting Documentation
- Immunization Registry (Objective 8 Measure 1)
- An EP or EH can attest to the immunization registry public health reporting option for Program Year 2021 as follows:
- CT WIZ went live in September 2018. An EP who was mandated to report immunizations and registered with CT WiZ prior to program year 2020 is not required to register again for active engagement and can resubmit their email from DPH to satisfy the PH Immunization Objective for Program Year 2020. The MUST certificate from the previous IIS, called CIRTS, is no longer accepted as supporting documentation.
- DPH has declared readiness for MU Stage 3 as of January 2020. To attest to MU Stage 3, an EP or EH can complete and submit the CT WiZ HL7 Application Form and DPH will send email notifications as evidence of each phase of the EHR onboarding process (registration, testing, production). These emails will be accepted as supporting documentation for EPs and EHs attesting to the Medicaid Interoperability Program and will meet the meaningful use objective for immunization reporting for MU Stage 3.
- For 2021, if you are excluding from this measure you must upload the 2021 Exclusion Letter below.
- An EP or EH can attest to the immunization registry public health reporting option for Program Year 2021 as follows:
- Syndromic Surveillance (Objective 8 Measure 2)
- Connecticut Department of Public Health (DPH) is not currently ready to receive syndromic surveillance data to meet the CEHRT standards. Connecticut EPs should exclude from this measure based upon the criteria that EPs “Operate in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data from EPs in the specific standards required to meet the CEHRT definition at the start of the EHR Reporting Period”.
- Electronic Case Reporting (Objective 8 Measure 3)
- DPH, as the Public Health Agency, does not operate or have the capability to accept electronic case reporting data. Eligible professionals are to claim an exclusion from this measure.
- Public Health Registry Reporting (Objective 8 Measure 4)
- DPH does not have the capability to accept public health registry data in a MU-compliant manner for EPs or EHs. Eligible Hospitals and professionals are to claim an exclusion from this measure.
- CDR Reporting (Objective 8 Measure 5)
- DPH, as the Public Health Agency, does not operate or have the capability to accept clinical data registry electronic data. However, CMS regulation states that clinical data registries are not limited to endorsement by the public health agency.
- Other Meaningful Use Objective Exclusions
- If you are excluding from any Meaningful Use Objectives 1 through 7, you may not need to provide any additional information in the application. However, if a discrepancy is identified, you may be asked for proof of why you excluded during the pre-payment or post-payment audit.
Eligible Professional (EP) Overview
What is EHR?
An Electronic Health Record (EHR) is an electronic version of a patient’s medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates access to information and has the potential to streamline the clinician’s workflow. The EHR also has the ability to support other care-related activities directly or indirectly through various interfaces, including evidence-based decision support, quality management, and outcomes reporting.
What is Certified EHR?
To avoid a Medicare payment adjustment or to receive a Medicaid incentive payment, health care providers must use an EHR that is certified specifically for the PI Program. CEHRT gives assurance to purchasers and other users that an EHR system or module offers the necessary technological capability, functionality, and security to help them meet the meaningful use criteria. Certification also helps health care providers and patients be confident that the electronic health IT products and systems they use are secure, can maintain data confidentially, and can work with other systems to share information.
To get an incentive payment, EPs must use an EHR that is certified specifically for the PI Program.
To find a certified EHR, go to ONC’s Certified Health IT Product List.
- Register with CMS online at https://ehrincentives.cms.gov/.
- Once you have registered with CMS and MAPIR has received and matched your provider information, you will receive an email to begin the MAPIR application process.
Eligible Professionals under the Medicaid PI Program include:
- Physicians (primarily doctors of medicine and doctors of osteopathy).
- Nurse practitioners.
- Certified nurse-midwifes.
- Physician assistants who furnishes services in a Federally Qualified Health Center or Rural Health Clinic that is led by a physician assistant.
To qualify for an incentive payment under the Medicaid PI Program, an Eligible Professional must meet one of the following criteria:
- Have a minimum 30% Medicaid patient volume.*
- Have a minimum 20% Medicaid patient volume, and is a pediatrician.*
- Practice predominantly in a Federally Qualified Health Center or Rural Health Center and have a minimum 30% patient volume attributable to needy individuals.
* Children’s Health Insurance Program (CHIP) patients do not count toward the Medicaid patient volume criteria. In CT, Husky B claims are CHIP claims and should not be included in an EPs numerator unless the EP can include a needy individuals patient volume as noted above.
Security Risk Analysis
A Security Risk Assessment must be completed each year in order to qualify for the PI Incentive Payment. The entire SRA must be submitted for the 2021 Program Year. The SRA will be reviewed for compliance with program requirements before an incentive payment is issued. Please refer to the Tips for Completing a Security Risk Analysis below.
Post payment audits are conducted on a random sample of providers who attest each year. Please refer to the Eligible Professional Post Payment Review Tips below, so you are prepared in the event you are chosen for audit.
** The term “audit” as used in the CT Medicaid PI Program educational materials does not imply an audit as defined by the American Institute of Certified Public Accountants.
After the first year of participation, EPs must demonstrate that they have meaningfully used their certified EHR by completing the following:
- 2020 and 2021 Stage 3: 8 Meaningful Use Objectives
- 6 Clinical Quality Measures
CMS recently released an updated final rule that specifies the criteria eligible professionals (EPs) must meet in order to participate in the PI Program. These changes apply to Meaningful Use attestations in program years 2015 through 2018 as well as Stage 3 in 2019 and beyond.
For Program Year 2021, providers are required to attest to Stage 3 Objectives. To attest to Stage 3, the EHR system must be certified to 2015 standards by the last day of the reporting period.
Meaningful Use Objectives
In Stage 3, EPs must attest to 8 Objectives, including one consolidated Public Health Measure.
|1. Protect Patient Health Information|
|2. Electronic Prescribing|
|3. Clinical Decision Support (CDS)|
|4. Computerized Provider Order Entry (CPOE)|
|5. Patient Electronic Access to Health Information|
|6. Coordination of Care through Patient Engagement|
|7. Health Information Exchange|
|8. Public Health and Clinical Data Registry Reporting|
Clinical Quality Measures
Clinical quality measures, or CQMs, are tools that help measure and track the quality of health care services provided by eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) within our health care system. These measures use data associated with health care providers’ ability to deliver high-quality care or relate to long-term goals for quality health care. To participate in the Connecticut Medicaid Electronic Health Record (EHR) Incentive Programs and receive an incentive payment, health care providers are required to submit CQM data from certified EHR technology.
MU and CQM CEHRT Reports
EHR technology certified to 2015 Edition
- Required to have the EHR technology certified to all 16 available CQMs
- Would not require recertification each time updated to the most recent version of CQMs and continues to meet 2015 Edition certification criteria
CQM reporting requirements for Medicaid health care providers in 2021:
|# of CQMs||Manual Attestation||6|
|Reporting Period||Manual Attestation||Continuous 90-Day Period|
Frequently Asked Questions
Am I eligible to attest for the PI Program?
As of Program Year 2017, the PI Program is no longer accepting first time attesters (AIU) into the program. Therefore, to qualify, you must have completed and been paid for at least one prior attestation, as well as match all of the requirements. Attest by visiting the MAPIR website. The system will prompt the attester for certain necessary information.
For more information on eligibility and requirements, please see the Eligible Professionals section above.
How do I recover password or user information for a provider?
Providers are required to have two separate sets of login credentials. EPs must log into the CMS’ PI Program Registration and Attestation System (CMS R&A) to make any modifications to their existing registrations. The CMS R&A site can be found here: https://ehrincentives.cms.gov.
Providers are also required to have a login for the MAPIR website for Attestation. Providers who need assistance with MAPIR login credentials may contact the PI Program Information Center at 1-855-313-6638 or email@example.com.
What is the required supporting documentation for the PI Program?
The supporting documents are Patient Encounter List (PEL), Purchase Order/Invoice, CEHRT/Cart Page, Security Risk Assessment (SRA), MU and CQM CEHRT Reports, Objective 8 Supporting Documentation and Exclusion documents (if qualified to exclude).
For all information on supporting documents and templates, please visit the Supporting Documents section above.
What is the reporting period for providers?
There are two separate Reporting Periods:
- The Patient Volume Reporting Period is either:
- Any 90 Day Period within the year preceding the payment year (for Program Year 2021, this is any 90 days within 2020).
- Any 90 Day Period within the 12 months prior to the date of attestation (if the attestation is completed on 6/3/2021, this is any 90 days between 6/3/2020 and 6/3/2021). This period can change. If the attestation dates are changed in MAPIR, the new 12-month period is prior to the day the dates are changed (if the provider changes the dates on 6/15/2021, then the new 12-month period is 6/15/2020 to 6/15/2021).
- The PI Reporting Period has two components:
- The Meaningful Use Objectives must be collected over any 90 Day Period within the Program Year (for Program Year 2021, this is any 90 days within 2021).
- The Clinical Quality Measures (CQMs) must be collected over a 90 day reporting period.
The Reporting Period for Patient Volume and PI Attestation can be different.
One of the questions in past attestations stated that 50% of all encounters and 80% of all unique patients have their data in the certified EHR during the reporting period. Can you please clarify this? Does this mean 80% of the unique patients within the 50% of all encounters?
A unique patient can have multiple encounters. Therefore, 50% of all encounters are different from 80% of all unique patients. If you have 100 patients but 320 encounters, you need to have 80 patients and 160 encounters.
What is the exact format for the Patient Encounters List?
For more information on the PEL and/or to download a useable template, please visit the Supporting Documents section above.
Are patients considered "duplicates" when they are listed twice for the SAME date of service, or the entire PEL itself?
Encounters are considered duplicates if they are for the same patient, on the same day of service, for the same provider. If they do not meet these criteria, then they are unique encounters and you should include them.
How can I extend the automatic duplicator to make it easier to filter duplicates?
If you go to the last, filled cell of the automatic duplicator, hover over the bottom right hand corner and a black plus should appear. Double click with the black plus, and that should drag and drop it to the entire column.
If I am attesting as a group, should the same PEL be uploaded for all the providers or should the PELs be individualized?
The same PEL should be uploaded for everyone in the group. In addition, all providers must also have the same patient volumes.
Can a contract be counted as a purchase order or invoice?
No, unless within the contract, there is a statement saying that the EHR system is a free service. For more information on Purchase Order, please visit the Supporting Documents section above.
If my 90 days Patient Volume data fall amongst 2 years (example Dec 2020-March 2021), what year does my SRA have to be from?
SRA has to be from whatever program year you are attesting to. If you are attesting to Program Year 2021, your SRA has to be from 2021 regardless of the data years.
My registration on CMS is currently stuck in "In Progress" status, how do I get out of this to move towards the payment process?
Log into the CMS R&A system and resubmit the Registration so that your attestation in MAPIR can proceed through the payment process. Follow all the steps there. If you have questions, call the contact number on the Login Page.
Will we be able to attest to Modified State 2 for Program Year 2021?
No, eligible professionals are required to attest to Stage 3.
I have received six payments, should I still attest?
No. EPs can receive up to six payments, once they have received six payments, they are no longer eligible for the program and should not attest.
Please follow this link for Important Messages
Frequently Asked Questions (FAQs)
- CMS Registration & Attestation System
- ONC Certified HIT Product List (CHPL)
- My PI Participation Timeline
Eligible Professionals (EPs)
- CMS Registration User Guide for Medicaid Eligible Professionals
- Eligible Professional CT User Manual
Meaningful Use and Clinical Quality Measures
- Clinical Quality Tipsheet
- 2021 Public Health Letter
- Stage 3 Attestation User Guide for Eligible Professionals