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Instructions for Completing the Medicaid Eligibility WorksheetReturn the completed Medicaid Eligibility worksheet to: [email protected] worksheet has multiple tabs: Tab 1: Fill in the worksheet: Complete for each provider applying for the program year. Instructions are included below for completing the worksheetstep by step. Multiple providers can be listed on one worksheet. Tab 2: Required Documentation – Review this tab and make sure to provide this documentation when submitting this worksheet and MU data. We arerequesting some information upfront because some providers have had payments recuperated due to lack of supporting documentation. to assist you tohave the documentation readily available for future audits. Tab 3: Patient Volume Calculation: Complete with your Medicaid Eligibility calculation for this program year application. Instruction links are on thetab where the data is entered. We have included a template for your use to track the data that backs up the patient volume calculation.Click each link below for additional information:Patient Volume Options – 2020.pdfPatient Volume Verification Template (Excel) Tab 4: Tip sheet: Audits - Tip sheet describing the audit process and documentation requirements for the program Tab 5: Version –version of the worksheetClick here to go to our website for more information for the 2020 program year2020 Medicaid Eligibility WorksheetStep by Step Instructions The table below is located on the Fill in the worksheet tab at the top of the page. The person submitted the worksheet should enter theircontact info here.1.2.3.4.v.9.18Preparer's NameBest Method ofContactPhoneEmailName of person completing this worksheetemail or phone for the person completing [email protected]

For all cells that have a drop-down option please click the cell then the drop-down arrow to select one optionWorksheet Item5.6.Provider Name List each provider name; one per line2020ApplicationOptions(click cell, then dropdown arrow to selectone option)7.NotesProvider'sPersonal NPINumberAll providers are required to submit Stage 3 for 2020 and must have 2015 editionCEHRT for entire reporting period.List the eligible provider (EP) personal NPI numberThe following provider types are eligible for the Medicaid MU Incentive program:MD (Medical Doctor), DO (Doctor of Osteopathy, DMD (Dentists), OD(Optometrist), PA (Physician Assistant), NP (Nurse Practitioner), CNM (CertifiedNurse Midwife).8.ProviderLicense Type(click cell, then dropdown arrow to selectone option)Physician Assistant -Additional documentation required9.v.9.18ProviderSpecialtyExampleExample Row:Granger MD, HermioneList the provider's specialty. If the provider’s specialty is not listed on theregistration it can be added by inserting on the I&A site.Provider types include but are not exclusive to: Psychiatrist, Cardiologist,Pediatrician, Family Practice, Surgeon, etc.Type in: 9-digit provider NPIImportant Note for PA's: Physician Assistant (PA)is eligible only when they are practicing at aFederally Qualified Health Center (FQHC) that isled by a PA or a Rural Health Center (RHC) that isso led. All PA's must submit documentation thatthey meet this definition prior to receiving payment.Examples of documentation could include: timesheets showing the PA is the primary care giver at asite (if an MD or DO gives care at the sitedocumentation is required to show they are not theprimary care giver); documentation that a PA is theowner of the site.If the site has a PA as the lead, then all PA’s at thesite are eligible.Type in specialty: example: Family Practice

10.Payee Name11.Assignment ofPaymentDocumentation(click cell, then dropdown arrow to selectone option)12.Payee rviceLocationMultiple SitesIf a provider is assigning payment list the payee name. Example: Dr. A isassigning his payment to the practice where he is under contract. List the name ofthe practice where the provider wants the payment to go.The Medicaid EHR Incentive program is a provider-based program. It is up to theprovider to determine where the payment is disbursed. If the provider elects, or isunder contract to assign their payment, the payee that receives the payment mustretain documentation that supports the provider’s decision. If a provider is notassigning to another entity, select "Not applicable".If provider is assigning payment select "Yes, I have documentation that supportsthe provider's assignment of payment to the listed payee". Most contracts havelanguage that dictates a provider is required to assign federal payments to theiremployer. The contract would serve as documentation.Enter the payee NPI that will receive payment. This NPI must be capable ofreceiving payments from MaineCare.Important* The payee NPI that is entered on the provider's registration in theCMS NLR (National Level Repository) is the payee NPI that will receive payment.You are responsible for updating the NLR registration to reflect the correct payeeNPI. We, (Maine MU program) cannot change the payee NPI information that issent to us from the NLR on the provider’s registration.List the organization structure for each provider.1. Parent2. Practice3. Size of practice (the number of providers at the practice is not limited to thoseproviders participating in the Maine Medicaid EHR Incentive Program)14a. Type in yes or no if a provider works at additional sites outside of asingle organization.Type in payee name: Example: XYZ FamilyMedicineType in the 9-digit NPI for the payeeType in the organization structure:Parent: XYZ Healthcare; HermionePractice: XYZ Family Medicine; HermioneSize: 8 providersExample: XYZ Family Medicine123 Medical PlaceAugusta, MEImportant Note: if a provider works at multiplesites, the provider is responsible for obtaining allMU reports from all sites. The data will be combinedand submitted to the program by the personsubmitting for the provider.

15.Providersworking at anFQHC orRHC (click cell,then drop down arrowto select one option)This applies only to providers currently working in an FQHC or RHC. If you donot work at an FQHC or RHC enter NA or leave blank. If the provider works at anFQHC/RHC they must meet the definition of "practices predominantly".Practices predominantly, means an EP for whom the clinical location for over 50percent of his or her total patient encounters over a period of 6 months in the mostrecent calendar year or the preceding 12-month period prior to this applicationoccurs at a FQHC or RHC. If a provider has not worked at an FQHC/RHC for 6months you must wait to apply when they meet the practices predominantlydefinition.Medicaid claims data from the calendar year prior to this application year areused to determine a provider's hospital-based status. A provider is consideredhospital-based when 90% or more of their services are performed in an InpatientHospital (code 21) or Emergency Room setting (code 23). Hospital-based providersare not eligible for the EHR Incentive Program and should not apply.16.Hospital-Based If a provider is hospital-based but additionally perform services greater than 10%outside of the Inpatient or ER setting and have documentation to support thoseStatusambulatory services, you are eligible to apply.(click cell, then dropdown arrow to selectone option)17.Maine's HealthDoes the provider participate in Maine's Health Information Exchange (HIE)Informationthrough HealthInfoNet?ExchangeUse theseresources to findyour CEHRT IDand specifications18.18a.v.9.18In a post-payment audit Medicaid claims will be used to determine hospital-basedeligibility. If the Medicaid claims alone show a provider is hospital based than allclaims data will be requested to show the provider is not hospital based. It isrecommended that you save any documentation for each program year as youreview it for the program year. A provider can fail a post payment audit ifsupporting documentation has not been maintained for each program year.See FAQ 3061 for more informationCEHRTProduct NameCEHRTVendorDeveloperIt is mandatory that you select the statement thatthe provider is eligible for this program year and has 10% of encounters outside of billing code 21 or 23.If a provider is hospital based in the year prior to theapplication year ( 90% of services were billed tocode 21 or 23) they are not eligible to apply.type in Yes or NoCEHRT – Certified Health Information Technology2020 CHPL Site Guide PDFClick here to go the CHPL siteUse this guide to generate the CMS Certification IDfor your CEHRT product.List the name of the CEHRT in use for this applicationList the name of the vendor(pdf will open in a separate window)

18b.18c.18d.18f.CEHRTProductVersion #CHPL ID orCHPL ProductNumberCMS EHRCertificationIDCEHRT is2015 CertifiedList the CEHRT Product Version #List the CHPL Product Number2020 CHPL Site Guide PDFList the generated CMS EHR Certification ID number.Refer to guide listed above for assistance.Please note: all 2015 edition CEHRT ID will begin with 0015For 2020 you must submit Stage 3 and must be on 2015 edition CEHRTSelect how the Medicaid Eligibility Calculation was determined.Select one: Individual provider encounters only or Practice/Group level encountersIndividual Provider encounters will be based on only that providers 90-day periodof Medicaid encounters. Only that provider may use that k cell, then dropdown arrow to selectone option)v.9.18See the CHPL Site Guide to find how to create theCMS certification ID and the CHPL number.Practice/Group level considers all services from the practice site and calculatesthe Medicaid eligibility based on that data. Using the Practice/Group level allowsall providers at that site to use the practice/group calculation as a proxy if the sitehas 30% or greater Medicaid encounters for a 90-day period.The two guides listed below will assist you in the calculation and tracking of thepatient volume calculation. Click them to open.2020-Medicaid Patient Volume Calculation Options PDFPatient Volume Verification Template (Excel)The template will download in your browser. Click the doc in the lower left side todownload and save.type in: Yes or No for 2015 CEHRT edition

Stage 3-PublicHealth Reporting Tip Sheet-PDF20.21.v.9.18Objective 10:Public HealthRegistrationDate(required for allproviders)Public HealthRegistries Enter the date that the provider’s practice or individual provider wasregistered with Maine’s Public Health Registry; and what registries wereselected for the provider. The date is the original date of the practice site PH registration. The 2020requirements state that the registration date must be any time prior to orwithin the first 60 days of the providers reporting period. Once a practice site is registered, in any previous year, and the provider islisted in the registration you do not need to register again. Once a practice site is registered you can add/remove people from theregistration as providers change locations. When you add a provider to the practice registration, they will use theoriginal date of the practice registration as a proxy and not the date theywere added to the practice site registration. Type in all registries that the provider is registered for. The registries should be within the provider’s scope of practice. Ex: if youdon’t treat Cancer, don’t register for that registry. Maine has the following 4 registries available:1. Immunization Registry (IR)2. Syndromic Surveillance Registry (SSR)3. Electronic Case Reporting (ECR)-available for the 2020 program year.4. Public Health Registry Reporting (Cancer and Specialty Registries willmove here for Stage 3) Currently not available in Maine5. Maine does not yet have the Clinical Data Registry (CDR) available. –Providers will be able to use the exclusion for this measure.Example 1: Practice A - registered with Maine’sPH registries on February 1, 2014. All providersworking at that practice were listed in the PHregistration and will use the February 1, 2014 date.If a provider joined Practice A in March of 2019, thepractice will add this new provider to any current PHregistries that apply to the provider’s scope ofpractice. The new provider can meet any registryrequirement for MU that is applicable and the datethey will use is the original date the practice wasregistered – in this example 2/1/14. The practiceregistration meets the requirement with the originalregistration date as it is prior to the new providersreporting period and the new provider is added byproxy.For more information on the Public Health Registriesplease contact:Immunization Registry: [email protected] to Maine CDC ImmPact pageSyndromic Surveillance Registry: [email protected] Case Reporting: [email protected] Registry: [email protected]

22.23.Exclusion forPublic HealthRegistriesPublic HealthImmunizationActiveEngagementStatus(click cell, then dropdown arrow to selectone option) Type in all registries that the provider meets the exclusion for:1. Immunization Registry (IR)2. Syndromic Surveillance Registry (SSR)3. Electronic Case Reporting (ECR)-available for the 2019 program year.4. Public Health Registry Reporting (Cancer and Specialty Registries will movehere for Stage 3) Currently not available in Maine5. Maine does not yet have the Clinical Data Registry (CDR) available. –Providers will be able to use the exclusion for this measure.If a provider is eligible for any exclusion (does notgive immunizations, etc.) they will need to answerall 5 measures by either meeting or excluding tomeet the objective.For the Immunization Registry note which stage of active engagement the practiceis in: Option 1 – Completed Registration to Submit Data Option 2 – Testing and Validation Option 3 - ProductionEnter the date the Security Risk Analysis (SRA) was completed or reviewed.Resources for the Security Risk Analysis – contains lin