Illinois FAQs - Eligible Professional (EP) 

Yes, once an EP has successfully registered at the federal CMS site, HFS will receive the registration record and will perform a series of initial edits including:

• Provider is enrolled with HFS
• Provider status is active
• Provider/Payee combination is valid
• Provider Type for the provider is eligible for this program
• Provider is not sanctioned

Refer to the HFS Path to Payment Page for additional details related to these edits.

No, EPs must choose to receive the payment from either Medicare or Medicaid.

HFS has received approval from federal CMS to extend the deadlines for registering and attesting for the Medicaid EHR/PIP to 90 days after the end of the calendar year for EPs and 90 days after the end of the federal fiscal year for eligible hospitals (EHs). The deadlines for registering and attesting for the 2011 payment are:

EP – March 31, 2012
EH – December 31, 2011

For the Medicare EHR Incentive Payment, the deadlines remain 60 days after the end of the calendar year for EPs (February 29, 2012) and 60 days after the end of the federal fiscal year for EHs (November 30, 2011). Additional important dates are found on the federal CMS Web site.

The Meaningful Use requirements to qualify for incentive payments were released on July 13, 2010. The Final Rule definitively outlines all the specifics of Stage 1 Meaningful Use and clinical quality measure reporting. A detailed description of these Meaningful Use measures is found on the CMS Web site.

EPs are not required to demonstrate Meaningful Use in their first payment year. During the EP’s first year, they are only required to attest that they have adopted, implemented, or upgraded certified EHR technology and there is no reporting period for this requirement.

EPs must demonstrate Meaningful Use in their second participation year. For this second participation year, the EHR reporting period is 90 consecutive days within the participation year.

There are several items to be considered when calculating Medicaid patient volume, including:

• Methodology for determining patient volume
• Individual volume vs. group proxy
• Methodology for determining Title XIX (Medicaid) percentage
• Out-of-state encounters

Each of these items will be discussed in detail below. Following is a general description of Medicaid patient volume from the federal CMS Web site:

The final rule:

• Specifies that eligible professionals and hospitals must meet patient volume thresholds, measured by a methodology selected by the state. The two options offered in the final rule include: 1) a ratio where the numerator is the total number of Medicaid patient encounters (or needy individuals) treated in any 90-day period in the previous calendar year, and the denominator is all patient encounters over the same period; or 2) a similar ratio where the state may take into account Medicaid patients on a primary care patient panel. For all eligible professionals except pediatricians, the minimum patient volume threshold is 30 percent; for pediatricians, it is 20 percent. Eligible professionals practicing at FQHCs/RHCs must demonstrate that more than 50 percent of their clinical encounters occurred at an FQHC/RHC over a six-month period, and that they had a minimum of 30 percent of their patient volume from needy individuals. Needy individuals are those receiving medical assistance from Medicaid or the Children's Health Insurance Program, individuals who are furnished uncompensated care by the provider, or individuals furnished services at either no cost or reduced cost based on a sliding scale determined by the individual’s ability to pay.

HFS Methodology for Determining Patient Volume

HFS has selected the first option above as the methodology for determining patient volume. Providers must include a ratio where the numerator is the total number of Medicaid patient encounters (or needy individuals for FQHCs and RHCs) treated in any 90-day period in the previous year, and the denominator is all patient encounters over the same period as illustrated below:

Individual Volume vs. Group Proxy

Medicaid patient volume thresholds may be met at the individual level (by provider NPI) or at the group practice level. Note that, per the Federal Final Rule governing this program, and as further clarified in CMS FAQ 10362, the following group practice/clinic level patient volume methodology can only be used if all of the following conditions are satisfied:

• The clinic or group practice’s patient volume is appropriate as a patient volume methodology calculation for the EP.
• For example, if Medicaid patients were served by the eligible professional during the 90-day period (for the first year).
• There is an auditable data source to support a clinic’s, or group practice’s, patient volume determination.
• All EPs in the group practice or clinic use the same methodology for the payment year.
• The 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 group practice, and not the EP’s outside encounters.

HFS Methodology for Determining Title XIX (Medicaid) Percentage

EPs Using Individual Patient Volume

The Final Rule requires that the Medicaid patient volume calculation be based on the Title XIX population only. In Illinois, our KidCare program was subsumed into All Kids in 2006. The All Kids program is the state’s health insurance program for children and consists of approximately 90% Title XIX, 5% Title XXI, and the balance (5%) is state funds only.

HFS anticipates that EPs will have difficulty in determining Medicaid patient volume because, by design, providers cannot distinguish between Title XIX (Medicaid), Title XXI (CHIP) and State Funded eligibility and payments. In order to assist providers with determining their Medicaid (Title XIX) patient volume, for individual EPs, HFS will post a list of Medicaid (Title XIX) percentages for each NPI. The percentage will be based on paid claims and accepted encounter data submitted for calendar year 2010 (CY’10) dates of service. Using the data available in the department’s system, HFS will identify which claims and encounter data were paid/accepted for Title XIX recipients as the Final Rule requires that Medicaid (or a Medicaid demonstration project approved under Section 1115 of the Act) paid for part or all of the services or Medicaid (or a Medicaid demonstration project approved under Section 1115 of the Act) paid all or part of the individual’s premiums, copayments, and cost-sharing. HFS will then divide the Medicaid (Title XIX) claims (excluding CHIP and state funded claims and encounter data) by total claims and encounter data to develop the Medicaid (Title XIX) percentage. Providers will apply the Title XIX percentage to establish their patient volume numerator.

Following is an example of the Title XIX percentage calculation for an individual EP and how that EP will apply the Title XIX percentage to calculate the Medicaid patient volume:

• HFS will derive the Title XIX percentage for all EPs based on provider type and will post a table containing the NPI and Title XIX percentage to our HFS EHR/PIP dedicated Web page.
• If Dr. Smith has 5,000 paid claims/accepted encounter data for CY’10 and 4,000 of those encounters are for Title XIX recipients, the Title XIX percentage for Dr. Smith is 80%. Dr. Smith checks the chart on the HFS EHR/PIP Web site, which shows Dr. Smith’s NPI and a Title XIX percentage of 80%.
• HFS will provide a Medicaid patient volume calculation worksheet for providers to print off and complete prior to registering for the Illinois EHR/PIP program. Providers can use this form to determine whether or not they meet the required Medicaid patient volume for the EHR/PIP program.
• Dr. Smith reviews the encounters in his practice management system and determines that, for a 90-day period from October 1, 2010 – December 29, 2010, he has 500 paid claims/accepted encounter data for HFS recipients and his total volume of encounters for this period is 1,000. 
• Dr. Smith will then check the table on the HFS Web site and see that his Title XIX percentage is 80%. The resulting calculation is as follows:

500 encounters x 80% = 400 encounters attributable to Title XIX

EPs Using Group Patient Volume

HFS does not have the capability to generate the Title XIX percentage for groups. Therefore, in order to facilitate group patient volume calculation, HFS will post a table containing the Title XIX percentage for each Illinois county. The use of the county-level percentage will be limited to providers using the group proxy methodology. The percentage will be based on paid claims and accepted encounter data submitted for CY’10 dates of service in that county. The group must select a county where they have a practice location.

Following is an example of the calculation for an EP using the group proxy:

• For purposes of this example, Dr. Jones practices in Sangamon County, which has a Title XIX patient volume value of 95%. He will be using XYZ’s group practice numbers for his patient volume.
• XYZ group practice reviews its encounters in the practice management system used for the group and determines that the group has 50,000 paid claims/accepted encounter data for HFS recipients for the 90-day period of October 1, 2010 – December 29, 2010, and the total volume of encounters for this period is 100,000. When Dr. Jones enters his attestation via the HFS MEDI attestation application, he will first indicate that he is attesting to patient volume using the group proxy (not as an individual) and will select Sangamon County. This will cause the Title XIX percentage field to auto-populate the value of 95% from the table on the HFS EHR/PIP Web site. Dr. Jones then enters 50,000 as the numerator for the Medicaid patient volume calculation. HFS will apply the 95% value to the numerator to derive the number of Title XIX encounters. In this case, the derived numerator is 47,500. Dr. Jones then enters the denominator from the practice management system (100,000) and MEDI auto-calculates the percentage of Medicaid patient volume which is 48% in this case.

50,000 encounters x 95% = 47,500 encounters attributable to Title XIX

Out-of-State Encounters

If you serve Medicaid patients from bordering states or if your practice location is in a border state, you may include the Medicaid patient volume from the state or location(s) only if that additional encounter volume is needed to meet the Medicaid patient volume threshold. If an EP aggregates Medicaid patient volume across states, HFS may audit any out-of-state encounter data before making the incentive payment. The EP must maintain auditable records for the duration of the HFS Medicaid EHR/PIP program.

HFS verifies that the payee information entered into the federal CMS registration Web site is valid compared to the payees associated with the provider in HFS’ system. If the payee is not associated with the provider in HFS’ system, the “Provider/Payee Combination Invalid” error is triggered. Following is a detailed explanation of the process for selecting the payee.

When an EP registers for the Medicaid EHR Incentive Payment program at the federal CMS Web site, they must select the Payee TIN Type. If the provider enters ‘SSN’ as the Payee TIN Type, this indicates that the provider receives the payment. If the provider enters ‘EIN’ as the Payee TIN Type, this indicates that a group receives the payment. As indicated above, for the Illinois Medicaid EHR/PIP program, the payee must be active on the provider’s HFS file. The “Provider/Payee Combination Invalid” error occurs when the information entered into the federal CMS application does not match the payee information on file with HFS.

In order to determine the action required to correct this error, the EP must first check the Provider Information Sheet sent from HFS. The valid payees are listed at the bottom of the Provider Information Sheet. Once the provider’s valid HFS payees are identified, there are two ways to remedy this error:

• If the HFS Provider Information Sheet contains the correct payees for the EP, the payee entered into the federal CMS registration application must be changed to one of the payees listed on the HFS Provider Information Sheet. Once the EP has updated the payee information via the federal CMS registration application, HFS will receive and process the updated record.
• If the HFS Provider Information Sheet does not contain the payee that the EP wishes to receive the incentive payment, the EP must contact the HFS Provider Participation Unit at 1‑217‑782‑0538 to enroll the payee. Once this enrollment process is complete, no additional action is required by the EP. HFS will reprocess the CMS registration record.

Once the error has been corrected, the EP will receive an e-mail indicating that the registration has been accepted and providing details regarding next steps (assuming all other edits are passed).

EPs must utilize auditable data sources to support their patient volume numbers. While HFS is not mandating any specific data sources, it is presumed that EPs will rely on practice management software/system or other business record keeping system or documentation for patient scheduling and billing.

EPs must retain the documents they relied on for the duration of the HFS Medicaid EHR/PIP program.

For more information about please visit the Official Web Site for the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs.

Can't find the answer to your question? E-mail HFS EHRIncentive Program.

EPs can switch between the Medicare and Medicaid Incentive Programs once during the incentive program.