THE CHICAGO HIT REGIONAL EXTENSION CENTERBringing Chicago together through health IT

Illinois Medicaid Promoting Interoperability Program

A Guide to Attesting for 2018with Sam Ross

Topics

• IMPACT and eMIPP• Starting an Attestation• Attestation Steps:

• Federal Information• Eligibility• Promoting Interoperability

• Objectives• Public Health Measures• Clinical Quality Measures

• Upload Document• Attestation

• Track an Attestation• Additional information

IMPACT and eMIPP

Login

• Visit https://impact.illinois.gov• Enter user ID and password, click Login

Home Page• Click “IMPACT”

Domain Selection• Select the individual provider for whom you are attesting from the first drop-

down box

• Don’t see the provider name? You’re not the domain administrator!

Profile Selection• Select Domain Administrator (or EHR Domain Administrator) profile from the

second drop-down; click “Go”

• Don’t see the profile you need? You’re not a domain administrator!

Accessing eMIPP

• Click “External Links”

Accessing eMIPP

• Click “EHR MIPP”

Start an Attestation

eMIPP Welcome Screen

• Click “Start” to access a 2018 attestation that has not been started or has not been submitted yet

• “Track” is only for reviewing previously submitted attestations

Search by CMS ID

• CMS ID is assigned upon initial CMS registration

• Can be found under Status tab at https://ehrincentives.cms.gov

• Must be the ID associated with the IMPACT provider (domain)

• Enter CMS ID and click “Search”

1000999999

Federal Information

Federal Information Tab

• Shows payment/program years for EP• Click the icon for the program year 2018 row

Additional tabs (click to open)

Active tab

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Federal Information Review

• Review Personal Information, Address, Identifiers, Exclusions and Prior Payments (not shown)

• It is extremely important that the Phone, E-Mail and Tax ID are correct

• Federal Information must be updated at https://ehrincentives.cms.gov

• When finished reviewing, click the “Close” button in the lower left to advance

Eligibility

Eligibility Tab

• Shows payment/program years for EP• Click the icon for the program year 2018 row

Active tabAdditional tabs (click to open)

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email@email.com

Eligibility Overview

• Identifying Information

• EHR Certification Information

• Organization Encounters

• Reporting Period

• Medicaid Patient Volume

EHR Certification Information

• EHR Status will automatically select “PI”

• Ask your vendor and/or search https://chpl.healthit.gov/#/search for Certification Numbers

• PI Reporting Choice: Stage 2 Modified or Stage 3 (if using 2015 CEHRT)

• Email: pre-populated from initial CMS registration

email@email.com

Reporting Period

• Historical 90-day billing period with 30% Medicaid encounters

• Two options• Prior Calendar Year (between 1/1/17 – 12/31/17)

• Prior Twelve Months (begins/ends within the 12 month period preceding attestation submission date)

• Enter start date, end date will calculate automatically

Organization Encounters

• Select “No” if EP is reporting individual encounter volume from eligibility reporting period

• Select “Yes” if EP is reporting group volume, then select organization from drop-down list

• Select “Yes” to “Use Group eCQM Data” only if uploading QRDAIII

Organization Encounters

• For the 1st EP selecting “Yes” to organization encounters, eMIPP will notify that eligibility data will be “read-only” (cannot be changed) for future attestations from EPs at the same organization

• For all other EPs at the same organization, eMIPP will notify that group eligibility data will be copied from 1st EP

(Notification for 1st group member) (Notification for all other group members)

Pediatrician/Physician Assistant

• Select “Yes” only if EP practices as a pediatrician, defined as board certified in pediatrics or 90%+ patient base under age 21

• Select “Yes” only if EP practices as a physician assistant (check all that apply)

Hospital Based/FQHC or RHC

• To simplify, select “No” to Hospital Based Provider

• Select “Yes” only if EP rendered any care in an FQHC/RHC

• Select FQHC or RHC and enter practice name

Encounter Types

• Enter volume for each encounter type:• Total = all encounters, all payers• Medicaid Fee For Service = encounters with public aid patients• Medicaid Managed Care Org = encounters with MCO patients• Total Medicaid = FFS + MCO (automatically calculated)

FQHC/RHC Encounter Types

• Enter volume for each type of encounter• Total = all encounters occurring at FQHC/RHC• Medicaid Fee For Service = encounters with public aid patients• Medicaid Managed Care Org = encounters with MCO patients• Total Medicaid = FFS + MCO (automatically calculated)• Charity Care Encounters = encounters provided free of charge• Sliding Fee Scale Encounters = encounters billed based on income

Billing NPIs

• If EP is a Nurse Practitioner, a “Billing NPIs” section will display:• Enter NPI numbers of all providers under whom the EP bills• If the EP does not bill under other provider NPI(s), just enter the NPI of the EP in the “Billing

NPI 1” box

No-Cost Encounters and Encounters Outside IL

• To simplify the process, select “No” to “Did you include no-cost encounters”

• No cost encounters are typically for “dual eligible” Medicare/Medicaid and should be included as Medicaid encounters

• Select “Yes” only if you included Medicaid encounters from outside Illinois in order to reach the 30% threshold• Enter state(s) in which encounters included above occurred• Will initiate audit verification check and delay payment

Save Eligibility Details

• After completing Eligibility Information section , click the button in the lower left corner to advance

Promoting Interoperability

Promoting Interoperability Tab

• Shows payment/program years for EP• Click the icon for the program year 2018 row

Active tabAdditional tabs (click to open)

PI Overview

5 navigation tabs at top, beginning with PI Overview

PI Reporting Period (at least 90 days)

CQM Reporting Period (full calendar year required)

Location Information

PI Overview: Reporting Period

• The reporting period can be any 90-365 days from 2018

• Not the same as eligibility reporting period

• Enter start and end date

PI Overview: CQM Reporting Period

• The CQM reporting period is required to be CY 2018

• Cannot modify start or end date

01/01/2018

12/31/2018

PI Overview: Location Information

• Enter the total number of outpatient locations where EP practiced

• Enter number of these locations equipped with certified EHR

• Enter the percentage of encounters occurring at locations where EP has a certified EHR (must be at least 80% to be eligible)

PI Overview: Submission Method

• Select “Online” to manually enter PI and CQM data through the Promoting Interoperability tab

• Select “PDF” to download a PDF that can be filled out offline and uploaded to populate the Promoting Interoperability tab

• Select “QRDA III” to upload a QRDA file that will populate only CQM data of the Promoting Interoperability tab

PI Overview Complete

• For those selecting “Online” submission, click the “PI -Objectives” tab at top to continue*

• For those selecting “PDF” and “QRDA III” submission, verify that all 3 items in the “Promoting Interoperability Completion” checklist are checked then click in the lower left to continue

* You may click the “Save” button at any time to save your progress

PI Objectives

• Must report compliance/exclusion on ALL 9 objectives to advance• Exclusions are yes/no• Compliance is yes/no or numerator/denominator

Click the title bar of an objective to open/close the reporting panel

PI Objectives (Yes/No)

1. Complete measure measure compliance fields

2. Click the title bar for the next objective to advance

PI Objectives (Num/Den)

1. Claim exclusion, if available

2. Attest to compliance (unless excluded)

3. Click the title bar for the next measure to advance

• You do not need to click the button after completing PI objectives; click the “PI -Public Health Measures” tab to advance

PI Objectives Complete

PI Objectives Public Health Measures

• Must report compliance with 2 objectives (unless excluded) to advance• Exclusions and compliance are yes/no

Click the title bar of a measure to open/close the reporting panel

1. Claim exclusion, if available

2. Attest to compliance and enter registry details (unless excluded)

3. Enter Registry Details

4. Click the title bar for the next measure to advance

PI Public Health Measures

PI Public Health Measures

• Specialized Registry Reporting includes attesting to “due diligence” of verifying registry availability from both:• Illinois Department of Public Health• Specialty societies to which you belong

• You do not need to click the button after completing PI Public Health Measures; click the “PI - Clinical Quality Measures” tab to advance

PI Public Health Measures

• Click the title bar to open/close the reporting panel and select CQM from within that domain

PI Clinical Quality Measures

• Must report on minimum 6 Clinical Quality Measures to advance

• Report numerator/denominator/exclusions/exceptions

PI Clinical Quality Measures

Click the title bar for a CQM within the domain to open/close the reporting panel for that CQM

Click the title bar for another domain to open the reporting panel

PI Clinical Quality Measures

1. Attest to compliance (numerator, denominator, exclusions/exceptions)

2. Click the title bar for another CQM you want to attest for in this domain

• After completing 9 PI objectives, 3 public health measures and 6 CQM, click the button to save your responses

Save PI Details

Upload Document

Upload Document Tab

• Attestations must include documentation supporting:• Patient volume (e.g. billing report showing Total/Medicaid encounters)• Public health measure achievement (confirmation of registry engagement)• FQHC only: UDS – Table 4 (patient characteristics)

• Encouraged to upload additional audit evidence• Click the button to upload for the 2018 program year

Active tabAdditional tabs (click to open)

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Browse for File

• Click “Browse” to locate the file on your computer and select• File type must be Word, Excel or PDF• Enter a file description (i.e. EHR receipt), click “Upload”

Attestation

Attestation Tab

• Read the attestation statement, click the check box in the lower left to accept the terms and conditions

• Click the “Register” button to complete attestation with a digital signature

Attestation Statements

• Review and check the box to agree to five mandatory attestation statements

• Review and choose whether or not to check the box to agree to two optional attestation statements

• Click the “Register” button

Attestation Submission

• Click “OK” to submit your EHR Registration for State Review (this is equivalent to “attestation”) or “Cancel” to go back

Attestation Confirmation

• If successful, you will see the Registration Confirmation page

• Click the PDF icon to download an attestation summary report

Track an Attestation

eMIPP Welcome Screen

• Click “Track” to view eligibility, PI and payment information from previous program years

• Note: If you are re-submitting or editing an attestation you didn’t finish, use the “Start” button

Track by CMS ID

• CMS ID is assigned upon initial CMS registration

• Can be found under Status tab at https://ehrincentives.cms.gov

• Must be the ID associated with the IMPACT provider (domain)

• Enter CMS ID and click “Search”

1000999999

Payment Information Tab

• Review program status and payment information for previous program years by clicking the “Payment Information” tab

Additional Information

Resources

• Webinars related to Promoting Interoperability at http://www.chitrec.org/webinars/archive/

• Patient volume pre-approval instructions: http://chitrec.org/blog/2016/12/09/pre-approval-open-for-volume-data-required-for-meaningful-use/

• Prepare for a successful attestation:• Manage issues with HFS - http://www.chitrec.org/wp-content/uploads/2017/11/Manage-MU-with-

HFS_12-12-17.pdf• Manage issues with CMS - http://www.chitrec.org/wp-content/uploads/2017/11/Manage-MU-with-CMS-

12-5-17.pdf

• Avoid rejection - http://www.chitrec.org/wp-content/uploads/2017/06/Avoid-MU-Rejection-Deck.pdf

• What happens in an audit - http://www.chitrec.org/wp-content/uploads/2017/06/Audit-Guidance-5-18-17.pdf