West Virginia Electronic Health Records (EHR) Provider Incentive Program (PIP) For Eligible Hospitals Meaningful Use Attestation Guide

Transcription

1 West Virginia Electronic Health Record Provider Incentive Program MEANINGFUL USE - Hospital West Virginia Electronic Health Records (EHR) Provider Incentive Program (PIP) For Eligible Hospitals Guide Date of Publication: 01/01/2014 Document Version: 1.0

2 Privacy Rules The Health Insurance Portability and Accountability Act of 1996 (HIPAA Public Law ) and the HIPAA Privacy Final Rule 1 and the American Recovery and Reinvestment Act (ARRA) of 2009 provides protection for personal health information. Protected health information (PHI) includes any health information and confidential information, whether verbal, written, or electronic, created, received, or maintained by Molina Healthcare. It is healthcare data plus identifying information that would allow the data to tie the medical information to a particular person. PHI relates to the past, present, and future physical or mental health of any individual or recipient; the provision of healthcare to an individual; or the past, present, or future payment for the provision of health care to an individual. Claims data, prior authorization information, and attachments such as medical records and consent forms are all PHI CFR Parts 160 and 164, Standards for Privacy of Individually Identifiable Health Information; Final Rule Page 2 of 129 Confidential and Proprietary

3 Revision History Version Date Author Action/Summary of Changes Status 1.0 3/12/2013 Karla Battle First Draft Active /09/2014 Joseph White Final QA Submission Confidential and Proprietary Page 3 of 129

4 Table of Contents Privacy Rules... 2 Revision History... 3 Table of Contents... 4 Table of Figures and Tables Introduction Registering with CMS Information Needed Required Supporting Documentation Finding EHR Certification Number Selecting Cost Reports System Requirements Navigation Breadcrumbs Use of the Navigation Features Help Link WV EHR Incentive Program Account Hyperlink Back to WV MMIS Portal link Home Tab Registration Tab Attestation Tab The Standard Buttons Using the WV EHR Incentive Program Application Login to the WV EHR Incentive Program Attestation Application Starting WV EHR Incentive Program Application Registration Registration Add Option Registration Select Option Registration Remove Option Attestation Attestation Eligibility Attestation Payment Schedule Certified EHR Technology Meaningful Use (MU) Core Questions Meaningful Use Core Question General Workflow Functionality Meaningful Use Menu Measures Meaningful Use Question General Workflow Functionality Clinical Quality Measures Clinical Quality Measures Meaningful Use Question General Workflow Functionality Page 4 of 129 Confidential and Proprietary

5 8.7 Submit Attestation and Payment Status Supporting Documentation References Status Grid Successful Registration with CMS Submitted Attestation Error Occurred when Processing Registration Provider Not Found Error Occurred While Processing Registration Medicaid Enrollment Failed Attestation Error Medicaid Claims Count Failed Attestation Accepted Attestation Payment Denied Attestation Payment Denied Pay Hold Found Attestation Paid Attestation Excluded from Payment Attestation Rejected Attestation Pended for Out of State Entries Attestation Failed Meaningful Use Enrolling in WV Medicaid Meaningful Use Core Measures Screen Shots Meaningful Use Menu Measures Questions Screen Shots Clinical Quality Measures Questions Screen Shots Confidential and Proprietary Page 5 of 129

6 Table of Figures and Tables Figure 1 Sample of Worksheet Figure 2 -- CMS ONC Certified EHR Product Screen Figure 3 -- Breadcrumbs Example Figure 4 Navigation Features Examples Figure 5 -- Update Account Screen Example Figure 6 Home Screen Example Figure 7 Registration Select Example Figure 8 -- Attestation Selection Example Figure 9 Standard Buttons Figure WV EHR Incentive Program application steps Figure 11 WV Login Screen Example Figure WV Welcome Page Example Figure 13 Provider Incentive About This Site Example Figure 14 Home Page Example Figure Registration tab Example Figure Registration Select and Add Example Figure 17 Add Registration Example Figure Registration Information Example Figure Registration Select Example Figure Registration Remove Example Figure Attestation Selection Example Figure Reason for Attestation Example Figure Verify Registration Information Example Figure Medicaid Volume Example Figure 25 Out-of-State Entry screen Figure 26 Out-of-State Add Entries screen Figure Payment Schedule Example Figure CMS EHR Buttons Example Page 6 of 129 Confidential and Proprietary

7 Figure 29 Meaningful Use Core Questions List Figure 30 Meaningful Use Menu Measures Question List Figure 31 Clinical Quality Measure Question List Figure Reason to Submit Attestation Example Figure Supporting Documentation Add Screen Figure 34 Submission Receipt Window Example Figure Attestation Status Grid Example Figure 36 Core Question 1A CPOE for Medication, Radiology, & Laboratory Orders Figure 37 Core Question 1B CPOE for Medication, Radiology, & Laboratory Orders Figure 38 - Core Question 1C CPOE for Medication, Radiology, & Laboratory Orders Figure 39 Core Question 2 Record Demographics Figure 40 Core Question 3 Record Vital Signs Figure 41 Core Question 4 Record Smoking Status Figure 42 Core Question 4 Record Smoking Status Numerator & Denominator Entry Screen 85 Figure 43 Core Question 5A Clinical Decision Support Rule Figure 44 Core Question 5B Clinical Decision Support Rule Figure 45 Core Question 6A Patient Electronic Access Figure 46 Core Question 6B Patient Electronic Access Figure 47 Core Question 6B Patient Electronic Access Figure 48 Core Question 7 Protect Electronic Health Information Figure 49 Core Question 8 Clinical Lab-Test Results Figure 50 Core Question 9 Patient Lists Figure 51 Core Question 10 Patient-Specific Education Resources Figure 52 Core Question 11 Medication Reconciliation Figure 53 Core Question 12A Summary of Care Figure 54 Core Question 12B Summary of Care Figure 55 Core Question 12C Summary of Care Figure 56 Core Question 13 Immunization Registries Data Submission Confidential and Proprietary Page 7 of 129

8 Figure 57 Core Question 13 Immunization Registries Data Submission Additional Information Entry Screen Figure 58 Core Question 14 Electronic Reportable Laboratory Results Figure 59 Core Question 14 Electronic Reportable Laboratory Results Additional Results Entry Screen Figure 60 - Core Question 15 Syndromic Surveillance Data Submission Figure 61 - Core Question 15 Syndromic Surveillance Data Submission Additional Information Entry Screen Figure 62 - Core Question 16 Electronic Medication Administration Record Figure 63 - Core Question 16 Electronic Medication Administration Record Numerator & Denominator Entry Screen Figure 64 - Menu Measures Question 1 Advance Directive Figure 65 - Menu Measures Question 1 Advance Directive Numerator & Denominator Entry Screen Figure 66 - Menu Measures Question 2 Electronic Notes Figure 67 - Menu Measures Question 3 Imaging Results Figure 68 - Menu Measures Question 4 Family Health History Figure 69 - Menu Measures Question 5 e-prescribing (erx) Figure 70 - Menu Measure Question 5 - e-prescribing (erx) Numerator & Denominator Entry Screen Figure 71 - Menu Measures Question 6 Lab Results to Ambulatory Providers Figure 72 - CQM Question 1 ED-1 Emergency Department Throughput - Median Time from ED Arrival to ED Departure for Admitted ED Patients Figure 73 - CQM Question 2 ED-2 Emergency Department Throughput Admitted Patients Admit Decision Time to ED Departure Figure 74 - CQM Question 3 Stroke-2 Ischemic Stroke - Discharged on Anti-thrombotic Therapy Figure 75 - CQM Question 4 Stroke - 3 Ischemic Stroke - Anticoagulation Therapy for Atrial Fib/Flutter Figure 76 - CQM Question 5 - Stroke - 4 Ischemic Stroke - Thrombolytic Therapy Page 8 of 129 Confidential and Proprietary

9 Figure 77 - CQM Question 6 Stroke - 5 Ischemic Stroke - Antithrombotic Therapy by End of Hosptial Day Two Figure 78 - CQM Question 7 - Stroke - 6 Ischemic Stroke - Discharged on Statin Medication 118 Figure 79 - CQM Question 8 Stroke - 8 Ischemic or Hemorrhagic Stroke - Stroke Education. 118 Figure 80 - CQM Question 9 Stroke-10 Ischemic or Hemorrhagic Stroke - Assessed for Rehabilitation Figure 81 - CQM Question 10 VTE-1 VTE Prophylaxis Figure 82 - CQM Question 11 VTE-2 ICU VTE Prophylaxis Figure 83 - CQM Question 12 - VTE-3 VTE Patients with Anticoagulation Overlap Therapy 120 Figure 84 - CQM Question 13 VTE-4 VTE Patients Receiving UFH with Dosages/Platelet Count Monitoring by Protocol Figure 85 - CQM Question 14 VTE-5 VTE Discharge Instructions Figure 86 - CQM Question 15 VTE-6 Incidence of potentially preventable VTE Figure 87 - CQM Question 16 AMI-2-Aspirin Prescribed at Discharge for AMI Figure 88 - CQM Question 17 PC-01 Elective Delivery Prior to 39 Completed Weeks Gestation Figure 89 - CQM Question 18 AMI-7a Fibrinolytic Therapy Received Within 30 minutes of Hospital Arrival Figure 90 - CQM Question 19 AMI-8a Primary PCI Received Within 90 minutes of Hospital Arrival Figure 91 - CQM Question 20 AMI-10 Statin Prescribed at Discharge Figure 92 - CQM Question 21 PN-6 Initial Antibiotic Selection for CAP in Immunocompetent Patients Figure 93 - CQM Question 22 SCIP-INF-1 Prophylactic Antibiotic Received within 1 hour Prior to Surgical Incision Figure 94 - CQM Question 23 SCIP-INF-2 Prophylactic Antibiotic Selection for Surgical Patients Figure 95 - CQM Question 24 SCIP-INF-9 Urinary Catheter Removed on Postoperative Day 1 or Postoperative Day 2 with Day of Surgery Being Day Zero Confidential and Proprietary Page 9 of 129

10 Figure 96 - CQM Question 25 ED-3 Median Time from ED Arrival to ED Departure for Discharged ED Patients Figure 97 - CQM Question 26 HMPC Document Given to Patient/Caregiver Figure 98 - CQM Question 27 Exclusive Breast Milk feeding Figure 99 - CQM Question 28 Healthy Term Newborn Figure CQM Measure 29 EHDI-1a Hearing Screening Before Hospital Discharge Page 10 of 129 Confidential and Proprietary

11 1. Introduction Starting in 2014, providers participating in the EHR Incentive Programs who have met Stage 1 Meaningful Use requirements for two years will need to meet Meaningful Use Stage 2 Meaningful Use criteria. This manual will assist you with your Stage 2 attestation. CMS has defined Meaningful Use in the following three stages: Stage 1 sets the baseline for electronic data capture and information sharing. Provider must receive two EHR Incentive Program payments for meeting these requirements before moving on to Stage 2. Stage 2, which is being implemented in 2014 Stage 3, which is expected to be implemented sometime in the future. CMS will continue to expand on the current baseline and continue to develop through future rule making. The Stage 2 requirements ONLY are introduced in this section. Attestation for Year 2 and beyond is not solely concentrated on meeting Meaningful Use and reporting on Clinical Quality Measures (CQMs). Hospitals are still required to be eligible for the incentive program for WV Medicaid; a hospital must be either actively enrolled with Medicaid as an acute care hospital, (including critical access hospitals or cancer hospitals) or a Medicaid enrolled children s hospital. The Center for Medicare & Medicaid Services (CMS) has defined eligible hospitals for the Electronic Health Record Incentive program for Medicaid as follows: Acute care hospitals (including CAHs and cancer hospitals) with at least 10% Medicaid patient volume Children's hospitals (no Medicaid patient volume requirements) Have an average length of stay of 25 days or fewer; AND have a CMS Certification Number (CCN) that ends with a number between or To determine whether the hospital meets the certification requirements to have a CCN in these ranges, reference should be made to the certification or conditions of participation (see 42 CFR Part 482). Eligible hospitals will then need to address Stage 2 Meaningful Use rules and questions approved by CMS, which are summarized as follows: 2014 Meaningful Use reporting Period Confidential and Proprietary Page 11 of 129

12 o According to the guidelines for the EHR Incentive Program, for 2014 all Meaningful Use reporting periods are 90 days, regardless of the reporting period used in prior years. After 2014, all Meaningful Use providers will need to meet the standards for their particular payment year. There are a total of 22 Meaningful Use objectives. To qualify for an incentive payment, 19 of these 22 objectives must be met. o o o There are 16 required core objectives. The remaining three objectives may be chosen from the list of six menu set objectives. The remaining questions are Clinical Quality Measures (CQMs). CMS rules are requiring that the provider reports on 16 of the 29 CQMs. Page 12 of 129 Confidential and Proprietary

13 1.2 Registering with CMS Hospitals do not need to register with CMS from Year 2 and beyond. However,, if any of the information included in a hospital s original CMS registration needs to be updated, the hospital should log into the CMS registration website to make these changes.. If you review your CMS registration and no changes are made, you will still need to resubmit the registration. If you do not, this will stop the processing of your attestation. Confidential and Proprietary Page 13 of 129

14 2. Information Needed Before a hospital can begin to complete the WV EHR Incentive Program attestation process, the hospital will need to gather all of the information necessary to complete the attestation correctly. The WV EHR Provider Incentive Program has created a workbook to guide the hospital through the data needed to complete an attestation successfully. The Workbook can be used to gather answers before logging in to the EHR Incentive Program Attestation Application. The items below provide the minimum that is needed in order to use the EHR Incentive Program Attestation Application in addition to the workbook. A sample page from the workbook is below (Figure 1). The FFS Medicaid counts for the attesting time period. The application will validate the entries. Currently enrolled within the attestation time period. CMS certification number, if not already found Information from the CMS-certified EHR system that answer the Meaningful Use and Clinical Quality measures. A Meaningful Use Work Sheet is available to help organize the information from the CMS-certified EHR system and the application. The work sheet will provide the following pages. o Volume page to record FFS Medicaid counts o Lists the Meaningful Use Core questions and the required information that the application requires for each question. o Lists the Meaningful Use Menu Measure questions and the required information that the application requires for each question. o Lists the Clinical Quality Measure questions with the numerators, denominators and exclusions. Page 14 of 129 Confidential and Proprietary

15 Figure 1 Sample of Worksheet Confidential and Proprietary Page 15 of 129

16 3. Required Supporting Documentation CMS and BMS recommend that you retain all documentation in case of audit. Providers must maintain records in accordance with Federal regulations for a period of 5 years, or 3 years after audits, with any and all exceptions having been declared resolved by the state s Medicaid office or the U.S. Department of Health and Human Services (DHHS). The provider must make all records and documentation available upon request to BMS and/or DHHS. Such records and documentation must include but not be limited to: Financial Records Hospital Information (credentials) Identification of Service Sites Supporting material used to measure Medicaid patient volume (including Excel spreadsheets or any other report identifying discharge dates and emergency department information used to count patient encounters Invoices, lease agreement, contract or other documentation supporting adoption, implementation, or upgrading of ONC-certified EHR technology EMR Reports supporting Meaningful Use attestation Out of State Documentation If the hospital plans to include encounter counts from another payer s state, the following documentation is required in an electronic format (PDF, Microsoft Word or Excel, or JPeg) and will need to be included with the electronic attestation. Certification on official letterhead from the state Medicaid agency declaring the numbers obtained were derived from the state s MMIS and are accurate. Report generated by the State Medicaid agency with the total Fee-for-Service and Managed Care Organization encounter count and reporting period. Please review BMS requirements and applicable provider manuals for the specific service requirements, retention periods, and lists. Page 16 of 129 Confidential and Proprietary

17 4. Finding EHR Certification Number The Office of the National Coordinator Authorized Testing and Certification Body (ONC- ATCB) tests and certifies electronic medical record (EHR) systems. If the EHR system is approved, it is assigned a certification number. The website below is the Certified Health IT Product List website to find an EHR certification number or even to register an EHR. Figure 2 -- CMS ONC Certified EHR Product Screen Confidential and Proprietary Page 17 of 129

18 5. Selecting Cost Reports It is imperative that the appropriate cost reports are selected. The hospital workbook provides the location of the cost report data element that is needed for the application. Please be aware that 42 CFR (g)(1)(i) (B) states that the discharge-related data amount must be calculated using a 12 month period that ends in the Federal fiscal year before the hospital s fiscal year that serves as the first payment year. To assist hospitals in determining the correct cost reporting period(s) to utilize in entering discharge and Medicaid share data used in calculating the HIT incentive payment, the following reference is provided: STEP 1: Enter the current federal fiscal year in which you are applying (If applying prior to 9/30/11 enter FY2011: if applying on or after 10/1/11 enter FY2012). STEP 2: Subtract from the date entered in Step 1, one fiscal year (Assuming FFY 2011 is entered, the date entered would be FFY 2010). STEP 3: Select the year end cost report that falls within the FFY identified in Step 2 a. If Hospital A YE = 12/31; Hospital A must report discharge and Medicaid share data using the cost report ending 12/31/2009 b. If Hospital B YE = 6/30; Hospital B must report discharge and Medicaid share data using the cost report ending 06/30/2010 c. If Hospital C YE = 9/30; Hospital C must report discharge and Medicaid share data using the cost report ending 09/30/2010 Page 18 of 129 Confidential and Proprietary

19 6. System Requirements To successfully use all features of the WV EHR Incentive Program, the computer system meets the following minimum requirements: Reliable internet connection. Web browser The latest version of Microsoft Internet Explorer (IE) is recommended or at least IE7. Earlier versions of IE may have display issues. Adobe Acrobat Reader. Confidential and Proprietary Page 19 of 129

20 7. Navigation 7.1 Breadcrumbs When a hyperlink is clicked, the appropriate web page is displayed to the right of the navigation bar. The breadcrumbs indicate the current position within the site. Breadcrumbs are a visual representation of pages and sub-pages followed to reach this page. You may select the underlined name to return to the specific page. For the example screen, the breadcrumb translates to the following: The gray text that is not underlined in the breadcrumb indicates the section that you are currently in. In this case it is the Meaningful Core Measures questions. The underlined text will display the page that it is assigned. An example of the breadcrumb is as follows: o displays the Reason for Attestation page. o displays the Attestation Instructions page. 7.2 Use of the Navigation Features Breadcrumb s Figure 3 -- Breadcrumbs Example Every screen of WV EHR Incentive Program has a set of standard navigation features. These are found on the upper right had corner of the application screens as shown below Help Link Figure 4 Navigation Features Examples CQM questions link to display a CMS document that displays all CQM questions. When selected, the CMS specifications for the question displays in a separate web browser window. An example of the link: Page 20 of 129 Confidential and Proprietary

21 7.2.2 WV EHR Incentive Program Account Hyperlink Displays a screen with address entry box. WV EHR Incentive Program application will use this address to send notifications regarding the attestations. The entry box allows the entry of a new address or updates to an existing one. Save changes by selecting the Update button. Press the Cancel button if you do not want changes saved Back to WV MMIS Portal link Figure 5 -- Update Account Screen Example Displays the WV MMIS Portal Welcome screen. Refer to Figure 12 -WV Welcome Page Example Home Tab Displays the Home screen as shown in Figure 6. Confidential and Proprietary Page 21 of 129

22 Figure 6 Home Screen Example Page 22 of 129 Confidential and Proprietary

23 7.2.5 Registration Tab Displays the registration instruction page as shown in Figure 7 below. Figure 7 Registration Select Example Confidential and Proprietary Page 23 of 129

24 7.2.6 Attestation Tab Displays the Attestation Home page shown in Figure 8. Figure 8 -- Attestation Selection Example Page 24 of 129 Confidential and Proprietary

25 7.2.7 The Standard Buttons There are certain buttons found below the fields of each functional screen that enable you to perform certain actions. The available actions depend on the purpose of the screen. The most common buttons found associated with WV EHR Incentive Program are Previous Screen and Save and Continue. Previous Screen will display the previous screen in screen sequence. Save and Continue must be selected or any entries in the screen will be lost and must be re-entered. A Submit button is also an option and is used when all entries are entered and the user is ready to submit the answers for review and possible payment. Figure 9 Standard Buttons Confidential and Proprietary Page 25 of 129

26 8. Using the WV EHR Incentive Program Application The WV EHR Incentive Program application guides the user through the CMS required questions to determine if a provider is eligible to receive provider incentive payments. Completing the hospital workbook will make the Question and Answer process more efficient within the application. A hospital may enter the information or assign someone to enter the information on their behalf. The different sections of the application are listed below. Each section will be discussed in detail. Pre-eligibility checks, which are completed on the receipt of a registration ID from CMS Login Instructions How to Register a Provider Entry of Eligibility Responses o Respond with Medicaid volume and determine if the amount is accurate. If not, then determine if certain criteria are met. Payment Schedule Entry of CMS EHR information, including Meaningful Use criteria and clinical quality measures Submit Attestation Figure 10 below is a pictorial view of the WV EHR Incentive Program application steps. Page 26 of 129 Confidential and Proprietary

27 Logs into WVMMIS.com Provider Portal Accesses link to PIP solution on Provider Portal Transferred to PIP solution Transferred to PIP Home Page PIP Provider Portal User Attest Attest Or Check Status Check Status Attestation Tab Status Tab Select attestation on Attestation Page Attestation Status Screen Presented with Attestation Topics Screen Respond to 3 or more Menu Measures Questions Payment/ Attestation history Details Screen Provider Registration Confirmation Screen Answer 16 or more Clinical Quality Measures Attestation Questionnaire Volume Entry Attestation Submit Page Payment Schedule View Screen Submission Confirmation Screen Respond to 16 Meaningful Use Core Questions Figure WV EHR Incentive Program application steps 8.1 Login to the WV EHR Incentive Program Attestation Application This section provides instructions on how to start the WV EHR Incentive Program application and logging into the system to use the application. Please obtain authorization from the provider to enter the data on their behalf Starting WV EHR Incentive Program Application The WV EHR Incentive Program application runs on the Internet. Execute the following steps to start the WV EHR Incentive Program application. Access the web portal main page. An example is below. Confidential and Proprietary Page 27 of 129

28 Enter User ID Enter password Click Submit Figure 11 WV Login Screen Example Prepare to Logon by entering the Logon Name and Password in the appropriate entry boxes and select Submit. Enter web portal user ID. Enter web portal password. Select Submit button. On the Welcome window, select the WV EHR Incentive Program option to display the Provider Incentive Program About This Site window. Refer to Figure 13 below. Page 28 of 129 Confidential and Proprietary

29 Figure WV Welcome Page Example Figure 13 Provider Incentive About This Site Example Confidential and Proprietary Page 29 of 129

30 On the Provider Incentive About This Site window, select the Continue button to display the Provider Incentive Program Notifications window (Home page). Refer to Figure 12 above. 8.2 Registration Figure 14 Home Page Example The Registration tab associates one or more provider registrations to a user ID, allows the user to view registration IDs that are attached to a user ID, and removes any provider registrations. For Stage 2, the following bulleted items are different scenarios and indicate if the registration process is executed: Page 30 of 129 Confidential and Proprietary

31 If you have submitted prior attestation and are eligible for Stage 2, you do not need to register. Your attestation will be ready when Stage 2 attestation is opened in the NJ EHR Provider Incentive Program application. Use the Attestation tab. If you have not submitted any attestations, you are not eligible for Stage 2 Meaningful Use. Please use the appropriate manual for your payment year. If you are a new user to submit on behalf of a provider who is eligible for Stage 2, you will need to register and follow the Add Registration instructions. Please ensure that you have the provider s permission to attest on his/her behalf. To view, add, and remove registrations, select the Registration tab on the navigation bar. Registration tab Figure Registration tab Example Upon selection, the Registration home screen displays. See Figure 16 below.. Confidential and Proprietary Page 31 of 129

32 Figure Registration Select and Add Example The Registration home page lists all registrations that you have added. If you have not added any, the Registration Selection section will display No records to display as shown in the figure below. Page 32 of 129 Confidential and Proprietary

33 The Registration sections below explain the options that are available on the Registration page: Add Option Select Option Remove Option Registration Add Option Figure 17 Add Registration Example Confidential and Proprietary Page 33 of 129

34 The following describes the steps to add a CMS registration to the EHR Incentive Program Attestation Application. Select the Add Registration button on the Registration home page. Enter Registration ID obtained from the CMS website. Enter the provider s NPI. Select the Add button. The system validates that the Registration ID is a valid ID assigned by CMS and that the correct NPI was entered with it. If valid, the registration ID and NPI are associated with the user ID. The Registration Information page displays with the registration information that was entered. Figure 18 is an example of the screen. The Previous Page button returns to the Registration Home Page. Figure Registration Information Example If invalid, an error message displays. The Add Registration page continues to display until the information is entered correctly or a navigation option is selected. Page 34 of 129 Confidential and Proprietary

35 Error Msg. Below are the most common reasons why an error occurred: Information is entered incorrectly. Correct the errors. If necessary, access the CMS website to check the registration information or add a registration. The registration ID will not be found if 48 hours has not expired after registering with CMS. The Cancel button is an additional option that is available. Selection of this button does not add the registration ID and the Registration Home screen displays. No additional registration ID displays Registration Select Option Select hyperlink Figure Registration Select Example When the Select link is selected, the registration details displays for the Registration ID selected. Figure 19 is an example. The Previous Page button displays the Registration Home page. Confidential and Proprietary Page 35 of 129

36 8.2.3 Registration Remove Option Remove hyperlink Figure Registration Remove Example Selecting the Remove option next to a registration ID will remove the registration ID from the user ID. The registration ID will no longer be displayed in the Registration Selection list or in the Attestation page. Figure 20 above is a portion of the Registration Instructions page and indicates where the Remove option is found. The Registration ID is still available to reassign by executing the Add Registration steps. Any information entered prior to removing the registration ID will display after reassigning. NOTE: If someone else has registered to attest for the provider, the data that was entered by this user will display. 8.3 Attestation The provider will select the registration and continue with populating the provider s attestation for that year. The solution will walk the eligible hospital through a series of Attestation screens with a questionnaire on Medicaid population, the practice location, and Meaningful Use and Clinical Quality Measure questions. The provider must complete these questions to proceed with submitting attestation. The hospital must complete these questions in order to proceed with submitting the attestation and potentially receiving payment. The workbook provides the answers that will be entered in the appropriate screen so that the provider is prepared to answer all related questions prior to beginning the attestation process The Attestation workflow consists of the following topics. The application will guide the user through each topic in sequence. Therefore, a topic will not become active until the previous topic has been completed. Each of the following topics will be addressed: Page 36 of 129 Confidential and Proprietary

37 Verify Registration Information Verify that the provider information is accurate and not from another provider Ability to indicate proxy usage Eligibility Screens These screens walk the provider through the attestation specific eligibility questions that must be completed to be validated as an eligible provider for the Incentive Program These screens include: Questions on provider Medicaid volume Display of the Payment Screen Displays the payment amounts calculated during Year 1 attestation. Certified EHR Technology Screen This screen validates that the provider is indeed using a valid EHR solution for the purposes of supporting Meaningful Use in Years 2-6. Meaningful Use Core Measures There are sixteen required questions. Meaningful Use Menu Measures CMS requires a minimum response to three questions. Six questions are provided. Core Clinical Quality Measures CMS requires a minimum response to 16 questions. 29 CQMS are provided. The Attestation process is accessible by selecting the Attestation Tab. When selected, the Attestation Instructions page displays. This page indicates the registration IDs that are assigned to the user ID. The Attestation process does not need to be completed in one session. Each screen in the Attestation flow has a Save and Continue button. This will save changes and allow the user to stop at any time without the loss of data that has been entered on that page. The attestation process does not allow the user to skip forward to screens or jump past a screen without entering data. The user may edit answers until the attestation has been submitted. Confidential and Proprietary Page 37 of 129

38 To start the attestation process Select the Attestation option on the row for the Registration information. Figure Attestation Selection Example Review the Attestation status displayed on the Attestation Topics Page. If the hospital is not listed, please select the Status tab. The Status tab will display the current Page 38 of 129 Confidential and Proprietary

39 attestation. Locate the hospital in the list to see the error that prevented the provider from executing the attestation process. The topics available on this page are as follows: Topic listing Figure Reason for Attestation Example The topic listing identifies the completed topic by placing a check mark next to the topic. A topic is completed when the required answers are entered and saved. Topics become available as prerequisite topics are completed. Select the Start Attestation button to start the attestation process or to continue to add and modify data already entered. Select the Submit & Attest button when all data is entered and verified. Changes may be made up to 48 hours after submission. After 48 hours expire, the data is submitted to the State for review. The Submit & Attest button is disabled on the initial selection of a registration ID. The Submit & Attest button is disabled if the Eligibility check was set to Ineligible. Select the Previous page button to display the Attestation Instructions page. Confidential and Proprietary Page 39 of 129

40 Upon selection of the Start Attestation button, the Registration Information will display. Figure Verify Registration Information Example Select Medicaid ID using the dropdown box Select the Medicaid ID to attest for. A provider can have one-to-many Medicaid IDs on file matching to the provider s single NPI on record. The designated NPI for institutional providers should be matched to its corresponding Medicaid ID the provider wishes to have the payment sent to ensure the appropriate match to the local Medicaid payee records. Select Continue button if after selecting the correct registration ID. Select Previous Page if the incorrect registration ID was selected or need to return to the Attestations Instructions page or select the Attestation Tab. Page 40 of 129 Confidential and Proprietary

41 8.3.1 Attestation Eligibility When the facility representative selects the organization s registration number associated with the facility and continues with the attestation portion of the WV EHR Incentive application process, the solution presents the user with a series of screens to complete the hospital s eligibility check under the regulations and to gather the appropriate data needed to calculate the provider s payment Eligibility Screen 1 Volume Check The purpose of this screen is to determine if the volume of Medicaid patients within the facility makes it potentially eligible for Medicaid EHR Incentive payment by the State. In order to be eligible for the Medicaid EHR Incentive Program the hospital must have: CAH or Acute Care Hospitals must have at least 10% Medicaid volume. Children s hospitals will not see this screen since they are exempt from volume check. WV EHR Incentive Program defines a hospital encounter as: A count of unduplicated count of Medicaid encounters for the provider in the 90 day period. An encounter for a hospital is defined as services rendered to an individual per inpatient discharge AND services rendered to an individual in an emergency department on any one day where Medicaid or a Medicaid demonstration paid for part or all of the service or paid all or part of their premiums, co-payments, and/or cost-sharing. In other words, an Eligible Hospital should count the following as one patient encounter: one to many claims for the same patient where the claim has the same DOS and the same rendering/attending provider. All claims related to the actual encounter with the patient for the same date, same provider. The WV EHR Incentive Payment solution includes a calculation to derive the number of unduplicated encounters for a provider by reviewing all Medicaid paid and reversed claims for the provider within the system for the timeframe specified during attestation. The West Virginia EHR Incentive Payment solution will run a report from the MMIS system to validate the FFS encounter count within the numerator. If the hospital has significant Medicaid encounters from another state payer, then you may add to the in-state encounter count to achieve the required encounter volume. The Volume page provides functionality to add and maintain out-of-state (OOS) volume counts. When an attestation with OOS entries is submitted, the attestation will be placed in a Pend status provide the in-state volume counts are validated. WV Medicaid department will review the attestation to ensure the appropriate documentation was provided and also to review the documentation to Confidential and Proprietary Page 41 of 129

42 determine if the attestation will be accepted. The hospital must obtain the counts from the OOS Medicaid MMIS and be prepared to submit the following documentation: Certification on official letterhead from the state Medicaid agency declaring the numbers obtained were derived from the State s MMIS and are accurate. Report generated by the State Medicaid agency with the total Fee-for-Service and Managed Care Organization encounter count and reporting period. Figure Medicaid Volume Example Page 42 of 129 Confidential and Proprietary

43 NOTE: An encounter for hospitals is defined as the number of inpatient discharges and the number of ER encounters over a 90 day period during the first incentive year and a full 12 months during subsequent years. An encounter is defined as an unduplicated personal direct contact or series of contacts occurring within the same day. Enter Start Date by typing in the date or selecting the Calendar Icon. The system will automatically calculate the 90 day end date. Enter the Numerator. Do not add commas. System will format with commas after entry. Enter the Denominator. Enter in MCO amount Do not add commas. System will format with commas after entry. Do not add commas. System will format with commas after entry. Enter Out-of-State (OOS) Counts (optional) The screen allows for entry of OOS entries. The following is a sample of a screen to display the different options available to the user. Each option s instructions are bulleted sections following this screen shot. To Add To Delete To Modify Figure 25 Out-of-State Entry screen Confidential and Proprietary Page 43 of 129

44 Figure 26 Out-of-State Add Entries screen To Add an OOS entry 1. Select Add State to display the screen above. 2. Select a State from the drop down list. 3. Enter Numerator for the State 4. Enter Denominator, which is the total patient encounters for the State 5. Select the Add button To enter in more States encounters, repeat Steps 1-5. To Modify OOS entry 1. Select Edit Page 44 of 129 Confidential and Proprietary

45 2. OOS Screen display with entries, correct entries 3. Select Update button To Delete OOS entry 1. Select Remove 2. Respond appropriately to the Are you sure? question. Select Save and Continue button to save all entries and changes including any OOS entries. The system validates if all fields have data entered. If any errors occur, check the dates, numerator, and denominator. Please enter the appropriate data. If no errors occur, the Payment Calculation pages displays Attestation Payment Schedule The Payment was calculated during the first year attestation. The Payment Schedule displays the amount that was calculated. WV Medicaid EHR Incentive Program payment distribution is to be distributed over a three year period as follows: 50% in the first year 40% in the second year 10% in the third year Confidential and Proprietary Page 45 of 129

46 Figure Payment Schedule Example Select Continue button to display the Certified EHR technology screen. Select Previous Page button to display the Eligibility screen. Page 46 of 129 Confidential and Proprietary

47 8.3.3 Certified EHR Technology Figure CMS EHR Buttons Example The Office of the National Coordinator Authorized Testing and Certification Body (ONC- ATCB) tests and certifies EHR systems. If the EHR system is approved, it is assigned a certification number. The website below is the Certified Health IT Product List website which can be used to look up the EHR to find the certification number or register the EHR. Please contact the Help Contacts listed on the Certified Health IT Product List website for questions. Enter the EHR Certification number Select the Meaningful Use option. Select the period that the EHR system was certified Confidential and Proprietary Page 47 of 129

48 The EHR period that displays is based on your payment as outlined below. o 90 day selection, date range controls display for the following conditions: AIU, which is the first year payment First year of Meaningful Use, second year of payment 2014 regardless of payment year o Otherwise, one year date range is required according to your payment schedule. Respond to the 80% of patients records are in an EHR If answered No, attestation progress is not allowed. Select Save and Continue button. The system validates if all fields have data entered. Error message displays if you did not: supply EHR Certification number select an required option supply a start and end date Page 48 of 129 Confidential and Proprietary

49 8.4 Meaningful Use (MU) Core Questions CMS requires that hospitals answer 17 questions to report Meaningful Use. The following screen below lists the questions currently required for Meaningful Use, Stage 2 reporting for Hospitals: Confidential and Proprietary Page 49 of 129

50 Page 50 of 129 Confidential and Proprietary

51 Figure 29 Meaningful Use Core Questions List Hospital Providers, please note that each MU question is required. The application will validate that all questions are completed during attestation, but does not validate that the questions meet the percentile required for Meaningful Use of an EHR system until after the attestation is submitted. After submission, the system will reject the provider if provider does not meet the requirement percentiles for appropriate EHR usage. This manual addresses the navigation of the Meaningful Use screens. The individual question screen shots are in the Meaningful Use Core Questions Screen Shots section. Confidential and Proprietary Page 51 of 129

52 8.4.1 Meaningful Use Core Question General Workflow Functionality Link to CMS definition Each screen has a link to the CMS definition and detail of each question for the provider to access to review the specific requirements for completing the numerator/denominator for each question and if elected, what the exception criteria must be for an organization to claim and exemption for that question. Save and Continue Button When selected, a check is executed to determine if all required fields have information entered. o If required fields are not filled, the page will continue to display until required fields are corrected. o If required fields are filled, the next screen displays. Previous Button Displays the previous screen. 8.5 Meaningful Use Menu Measures CMS has defined a total of six Meaningful Use Menu Measures. CMS is requiring the provider to select three questions. The individual question screen shots are in the Meaningful Use Menu Measures Screen shots section. The following screen shots list the Meaningful Use Menu Measures questions: Page 52 of 129 Confidential and Proprietary

53 Figure 30 Meaningful Use Menu Measures Question List User must select the questions to respond to by clicking in the box under the SELECT column for each question. A checkmark indicates that you have selected that question. The application will allow you to select more than five questions. Potential Error Messages on this Screen The following are the error messages if the minimum requirements are not meant: MESSAGE 1 - User receives the following error and cannot continue attestation process until error is fixed. Confidential and Proprietary Page 53 of 129

54 If the user selects less than three items, the following error message displays. Application Question Display for Menu Measures The application will only display the questions that were selected. The navigation is the same as was outlined in the Meaningful Use Core section, as show again below. The application will not validate if the required score has been met at the time of entry, it will only tell the user if the appropriate questions have been completed or not. The validation of EHR usage percentiles is done after the attestation is submitted Meaningful Use Question General Workflow Functionality Link to CMS definition Each MU question screen has a link to the CMS definition and detail of each question for the provider to access to review the specific requirements for completing the numerator/denominator for each question and if elected, what the exception criteria must be for an organization to claim and exemption for that question. Save and Continue Button When selected, a check is executed to determine if all required fields have information entered. o If required fields are not filled, the page will continue to display until required fields are corrected. o If required fields are filled, the next screen displays. Previous Button Displays the previous screen. 8.6 Clinical Quality Measures CMS rules require the hospital to report on a minimum of 16 CQMs. There are 29 CQMs available for selection. The application will not validate values entered except to validate that the appropriate type of answers were supplied, i.e. digits were entered for numeric fields. The individual question screenshots are in the Clincial Quality Measures Screenshots section (section 27). The following screen lists the CQMs. Page 54 of 129 Confidential and Proprietary

55 Confidential and Proprietary Page 55 of 129

56 Page 56 of 129 Confidential and Proprietary

57 Figure 31 Clinical Quality Measure Question List Confidential and Proprietary Page 57 of 129

58 8.6.1 Clinical Quality Measures Meaningful Use Question General Workflow Functionality To complete the CQM section, you must select a minimum of 16 CQMs out of a choice of 29 questions. The individual questions are displayed in Section 27: Clinical Quality Measures Screen Shots. The navigation is the same as was outlined in the Meaningful Use Core and Menu Measures section, but are repeated below. Potential Error Messages on this Screen The following is an example of the error messages if the minimum number of requirements is not met: MESSAGE 1 - User selects 14 CQMs. The error message displays the number of questions that need to be selected to meet the minimum requirement. Link to CMS definition Each screen has a link to the CMS definition and detail of each question for the provider to access to review the specific requirements for completing the numerator/denominator for each question and if elected, what the exception criteria must be for an organization to claim and exemption for that question. Save and Continue Button When selected, a check is executed to determine if all required fields have information entered. o If required fields are not filled, the page will continue to display until required fields are corrected. o If required fields are filled, the next screen displays. Previous Button Displays the previous screen Page 58 of 129 Confidential and Proprietary

59 8.7 Submit Attestation and Payment Status The Submit Attestation button remains disabled if the eligibility checks failed or not all required questions have been answered. If the eligibility checks passed and all required questions are answered, the Submit Attestation button is available. On selection of the Submit Attestation button, the following screen displays. Alternate address Add doc Delete doc Edit doc View doc Figure Reason to Submit Attestation Example Confidential and Proprietary Page 59 of 129

60 Enter an address if the one listed in the field is incorrect Supporting Documentation Documents may be in the form of PDF, JPeg, Excel, and Word files 4MB or smaller. Section 3 of this document lists required documentation. If you have entered OOS encounters, you are required to upload two documents, which are a certification letter that volumes are from the State s MMIS and the report from the State s MMIS department. To Add Document Select Add Document to display the following screen Select File to upload from the computer Figure Supporting Documentation Add Screen Select the Select button Page 60 of 129 Confidential and Proprietary

61 On Files window, navigate through the folders and select the file to upload, Select Ok. Document name displays in the File Name box. To Edit Document To Delete Document Enter in Title Enter in Description of file Select Add To add more files, Repeat Steps. Select Edit next to the desired document The Supporting Documentation Add screen fields displays with Update and Cancel buttons instead. Modify the information Select Update Select Delete next to the desired document Answer Are you sure? question appropriately Select Submit button. This displays the Successful Submission screen. An example is below. Confidential and Proprietary Page 61 of 129

62 Figure 34 Submission Receipt Window Example Upon successful submission, the attestation tasks have been completed. The WV Provider Incentive Program allows 48 hours to make changes the submitted application. If changes are made, the 48 hour count restarts. Once the 48 hours have expired, the WV Provider Incentive Program application will lock the attestation data and execute final eligibility checks by validating the hospital entered numbers are within a 10% variance of claims on file and query the CMS NLR to determine if payments have been paid. If the attestation passes the checks, the application will validate the Meaningful Use Core and Menu Measures met or exceeded the required percentage or the exception requirements. If not, then user will be notified via that Meaningful Use failed. This processing will take time and payment will not be sent right after submitting the attestation. After the eligibility checks and payment checks are executed, the WV Provider Incentive Program application will send an with the status that was found. If an eligibility or payment error has occurred and is in question, please contact the WV Medicaid Provider Services Help Desk at option 8. Page 62 of 129 Confidential and Proprietary

63 9. References Confidential and Proprietary Page 63 of 129

64 10. Status Grid The following table lists the attestation status that may occur. Figure Attestation Status Grid Example Page 64 of 129 Confidential and Proprietary

65 11. Successful Registration with CMS After registering with CMS, it may take up to 48 hours before this message is received. CMS processes the registrations and sends them to the appropriate State repository. The Provider Portal application will detect the registration in the WV State repository and process the registration. The Provider Portal application checks for valid provider type and active enrollment in Medicaid. When this message is received, logon to the Provider Portal to register and attest for this provider. Confidential and Proprietary Page 65 of 129

66 12. Submitted Attestation This is sent after the attestation is submitted. The system will wait two days to allow for user modifications. After the two days have passed, the system will execute the final edits. Page 66 of 129 Confidential and Proprietary

67 13. Error Occurred when Processing Registration Provider Not Found After the CMS registration arrives in the WV Provider Incentive Program application, validation of the provider is completed. This occurs if the provider does not exist in the MMIS. Confidential and Proprietary Page 67 of 129

68 14. Error Occurred While Processing Registration Medicaid Enrollment Failed The following checks are made when an attestation is received from the NLR. The below displays all the possible error messages for the following checks. Check if the provider is enrolled in Medicaid program during the attestation period. Check if the provider type that was selected when registering on the CMS site matches the provider type on the provider s enrollment record. Check if the payee NPI entered when registering on the CMS site is found when validating the attesting provider s payees on the Medicaid record. Page 68 of 129 Confidential and Proprietary

69 15. Attestation Error Medicaid Claims Count Failed The solution will check the provider s Medicaid claims that were submitted during the attestation period. If there were no claims found for the attestation period, the following is sent. If the solution found that claims counts could not be validated, then the following is sent. Confidential and Proprietary Page 69 of 129

70 16. Attestation Accepted This is sent when either one of the two scenarios occur. The 48 hour time span that allowed for changes has expired. The attestation is no longer accessible for changes within the application. The attestation details will be sent to the NLR to check if any payments have been made for the attesting provider. BMS has reviewed the failed attestation details and found that the attestation is acceptable. BMS set the status to an accepted status. The attestations details will be sent to the NLR to check if any payments have been made for the attesting provider. Page 70 of 129 Confidential and Proprietary

71 17. Attestation Payment Denied If final eligibility checks failed and payment issues occurred, a denial is sent. The Medicaid Provider Services staff at may be able to address the questions. Confidential and Proprietary Page 71 of 129

72 18. Attestation Payment Denied Pay Hold Found Payment is denied if the provider is on pay hold and this is sent if it is found. Page 72 of 129 Confidential and Proprietary

73 19. Attestation Paid If the final eligibility checks pass and no payment issues occurred, an indicating that the payment is approved and being processed is sent. The payment processing will continue. Payments will be sent after this processing. This could take several days. Confidential and Proprietary Page 73 of 129

74 20. Attestation Excluded from Payment This indicates that CMS already has a payment on record from the Medicaid payment. For questions or concerns, please contact the CMS NLR. The Medicaid Provider Services staff will not be able to assist in this instance. Page 74 of 129 Confidential and Proprietary

75 21. Attestation Rejected WV Medicaid and WV Medicaid Provider Services staff has the ability to review attestation and reject a submitted attestation. When the attestation is rejected, a rejection is sent. To find out more information, please contact the Medicaid Provider Services staff at , Option 8. Confidential and Proprietary Page 75 of 129

76 22. Attestation Pended for Out of State Entries If a submitted attestation has passed volume checks and has OOS entries, the attestation will be Pended. The WV Medicaid and WV Medicaid Provider Services staff will review the required documentation and determine if the attestation is acceptable. The following indicates that the attestation was Pended. To find out more information, please contact the Medicaid Provider Services staff at , Option 8. Page 76 of 129 Confidential and Proprietary

77 23. Attestation Failed Meaningful Use After the provider attestation passes the volume check and payment checks, the application will validate that the Meaningful Use Core and Menu Measures responses met or exceed the required response. If the user failed one or more questions, the following will be sent to notify that Meaningful Use failed. Confidential and Proprietary Page 77 of 129

78 24. Enrolling in WV Medicaid Healthcare providers supporting WV Medicaid patients must be active Medicaid enrolled providers for the timeframe that they will attest to the Medicaid patient volume and Electronic Health Record usage as it pertains to meeting the regulations. If the hospital meets the appropriate provider type and Medicaid volume requirements and is not actively enrolled as a West Virginia Medicaid provider at the time of attestation, then the provider must enroll with Medicaid to proceed with West Virginia EHR Provider Incentive Payment application. Please contact the WV Medicaid Provider Services Help Desk at between the hours of 8am and 5pm. Providers that enroll new to Medicaid will not be immediately eligible under the regulations and must wait the appropriate time to meet both the meaningful usage timeframes and Medicaid patient volume timeframes. Providers who have questions about current enrollment status, enrollment dates and enrolled type and specialty may also contact the WV Medicaid Provider Services Help Desk for assistance with enrollment. Page 78 of 129 Confidential and Proprietary

79 25. Meaningful Use Core Measures Screen Shots CMS requires a response to the 16 core measure questions. All possible screens are displayed below. The system will display each core question. However, the core question s supporting screens display is dependent on your response to the exclusion. An example of the supporting screen is the entry for numerator and denominator or to add results. Figure 36 Core Question 1A CPOE for Medication, Radiology, & Laboratory Orders Confidential and Proprietary Page 79 of 129

80 Figure 37 Core Question 1B CPOE for Medication, Radiology, & Laboratory Orders Page 80 of 129 Confidential and Proprietary

81 Figure 38 - Core Question 1C CPOE for Medication, Radiology, & Laboratory Orders Confidential and Proprietary Page 81 of 129

82 Figure 39 Core Question 2 Record Demographics Page 82 of 129 Confidential and Proprietary

83 Figure 40 Core Question 3 Record Vital Signs Confidential and Proprietary Page 83 of 129

84 Figure 41 Core Question 4 Record Smoking Status Page 84 of 129 Confidential and Proprietary

85 Figure 42 Core Question 4 Record Smoking Status Numerator & Denominator Entry Screen Confidential and Proprietary Page 85 of 129

86 Figure 43 Core Question 5A Clinical Decision Support Rule Page 86 of 129 Confidential and Proprietary

87 Figure 44 Core Question 5B Clinical Decision Support Rule Confidential and Proprietary Page 87 of 129

88 Figure 45 Core Question 6A Patient Electronic Access Page 88 of 129 Confidential and Proprietary

89 Figure 46 Core Question 6B Patient Electronic Access Confidential and Proprietary Page 89 of 129

90 Figure 47 Core Question 6B Patient Electronic Access Page 90 of 129 Confidential and Proprietary

91 Figure 48 Core Question 7 Protect Electronic Health Information Confidential and Proprietary Page 91 of 129

92 Figure 49 Core Question 8 Clinical Lab-Test Results Page 92 of 129 Confidential and Proprietary

93 Figure 50 Core Question 9 Patient Lists Confidential and Proprietary Page 93 of 129

94 Figure 51 Core Question 10 Patient-Specific Education Resources Page 94 of 129 Confidential and Proprietary

95 Figure 52 Core Question 11 Medication Reconciliation Confidential and Proprietary Page 95 of 129

96 Figure 53 Core Question 12A Summary of Care Page 96 of 129 Confidential and Proprietary

97 Figure 54 Core Question 12B Summary of Care Confidential and Proprietary Page 97 of 129

98 Figure 55 Core Question 12C Summary of Care Page 98 of 129 Confidential and Proprietary