Illinois Electronic Health Record Provider Incentive Payment (EHR/PIP) Program
To qualify for an incentive payment under the Illinois Medicaid EHR Incentive Program, an eligible professional must meet one of the following criteria for Medicaid patient volume:
- Have a minimum 30% Medicaid patient volume
- Have a minimum 20% Medicaid patient volume, and be a pediatrician; for the purposes of the Illinois Medicaid EHR Incentive Program, a pediatrician is defined as:
- A Medicaid enrolled provider who serves 90% of patients under the age of 21 based on the age of the patient at the time the service is rendered
or
- A Medicaid enrolled provider with a valid, unrestricted medical license and board certification in Pediatrics through either the ABP or the AOBP
- Practice predominantly in a Federally Qualified Health Center (FQHC) or Rural Health Center (RHC) and have a minimum 30% patient volume attributable to needy individuals
Types of Encounters to report as Medicaid encounters
Eligible Professional (EP)
- Title 19/21
- MCO Encounters
- Dual Eligible (Medicare/Medicaid)
- Due to transparency initiatives, providers cannot determine the difference between encounters billed for Title 19 Medicaid and Title 21 programs. The numerator must consist of all encounters billed to HFS as (Title 19 + 21). HFS will be deducting encounters billed for state only funded programs from the numerator and denominator during adjudication except for providers practicing predominantly in an FQHC/RHC in order to verify eligibility pursuant to legislation.
EP Practicing Predominantly* in an FQHC/RHC
- Title XIX (Medicaid)
- MCO Encounters
- Dual Eligible (Medicare/Medicaid)
- Needy Individuals – must meet one of the following criteria:
- Received medical assistance from Medicaid (Title XIX) or SCHIP (Title XXI)
- Were furnished uncompensated care by the provider
- Were furnished services at either no cost or reduced cost based on a sliding scale determined by the individual's ability to pay
*For this program, practicing predominantly in an FQHC/RHC means 50% or more of the total patient volume for the EP over a six-month period is at an FQHC/RHC
Group Practices
Clinics or group practices will be permitted to calculate patient volume at the group practice/clinic level only in accordance with all of the following limitations:
- The clinic or group practice's patient volume is appropriate as a patient volume methodology calculation for the EP
- There is an auditable data source to support the clinic's or group practice's patient volume determination
- All EPs in the group practice or clinic must use the same methodology for the payment year
- The clinic or group practice uses the entire practice or clinic's patient volume and does not limit patient volume in any way
- If an EP works inside and outside of the clinic or practice, then the patient volume calculation includes only those encounters associated with the clinic or group practice, and not the EP's outside encounters.
For more information about the Medicare or Medicaid EHR Incentive Program, please visit the federal CMS Web site or the HFS EHR Web site.
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