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FAQs - Indiana Medicaid Promoting Interoperability Program

Getting Started

The Indiana Medicaid PI Program Payment System (MAPIR)

Eligibility

  • Can an eligible professional who is not an active IHCP provider participate in the Indiana Medicaid PI Program?

    No. The provider needs to be an active IHCP provider to participate.

  • What are the eligibility requirements for eligible professionals?

    The eligible professional (EP):

    • Must be a qualifying EP provider type and be licensed and credentialed to work in his or her field
    • Must have no Office of Inspector General (OIG) exclusions
    • Must not be a hospital-based provider
    • Must have a minimum of 20% Medicaid patient volume if he or she is a pediatrician
    • Must have a minimum of 30% Medicaid patient volume if he or she is another type of eligible professional; OR must practice predominantly (more than 50% of clinical services) in a federally qualified health center or rural health clinic and have a minimum of 30% of his or her patient volume attributable to needy individuals (see response to "Can federally qualified health centers or rural health clinics partipate in the Indiana Medicaid PI Program?")
       

    EP provider types include the following:

    • Physicians (primarily doctors of medicine and doctors of osteopathy)
    • Nurse practitioners
    • Certified nurse-midwives
    • Dentists
    • Physician assistants who furnish services in a federally qualified health center or rural health clinic that is led by a physician assistant
  • What are the eligibility requirements for eligible hospitals?

    Acute care hospitals:

    • Must be Subsection(d) hospitals in the 50 United States or the District of Columbia, or critical access hospitals (CAHs)
    • Must have a qualifying CMS Certification Number
    • Must have a minimum of 10% Medicaid patient volume
       

    Children's hospitals:

    • Must have a qualifying CMS Certification Number
    • Have no minimum patient volume requirements
  • Can federally qualified health centers or rural health clinics participate in the Indiana Medicaid PI Program?

    Yes. To participate, the federally qualified health center or rural health clinic must have at least a 30% needy individual patient volume. Needy individuals are defined as individuals meeting any of the following criteria:

    • They are receiving medical assistance from Medicaid or the Children's Health Insurance Program (CHIP).
    • They are furnished uncompensated care by the provider.
    • They are furnished services at either no cost or a reduced cost, based on a sliding scale determined by the individual's ability to pay.
       

    Please contact the Indiana Medicaid PI Help Desk at (317) 488-5137 or 1-855-856-9563 for additional information.

  • If I switch participation from the Medicare PI Program to the Medicaid PI Program, how does it affect my participation?

    Eligible professionals (EPs) - after receiving at least one EHR incentive payment - may switch between the Medicare and Medicaid PI programs only one time, and only for one payment year before 2015. All EPs are required to meet 2 years of Stage 1 PI (formerly meaningful use) requirements in their first 2 years of PI before proceeding to Stage 2, regardless of whether their participation years are consecutive. (Note that providers that demonstrated PI in 2011 have 3 years in Stage 1; Stage 2 begins in 2014.)

    The final rule at 42 CFR 495.10(e) states that, upon switching incentive programs, the EP is "placed in the payment year the EP would have been in had the EP begun in and remained in the program to which he or she has switched." For example, if a provider's first participation year with the Medicare PI Program was in 2012, and the EP skipped the 2013 Medicare participation year, and then switched to the Medicaid PI Program in 2014, the EP would be in Stage 1, Payment Year 2, for Program Year 2014.

    Please contact the Indiana Medicaid PI Help Desk at (317) 488-5137 or 1-855-856-9563 or by email at MedicaidHealthIT@fssa.in.gov if you need to confirm your status before or after switching between the Medicare and Medicaid PI programs.

  • We currently use an EHR system that is not certified. Can we participate in the Indiana Medicaid PI Program?

    No. Eligible professionals and eligible hospitals need to be using a certified EHR product to participate in the program. For a list of certified EHR systems, please see the Certified Health IT Product List at the Office of the National Coordinator for Health Information Technology (ONC) website at oncchpl.force.com.

  • Am I required to use the same certified EHR system throughout my participation in the Indiana Medicaid PI Program?

    No. You can change certified EHR systems, if you wish. Each year, documentation from the Office of the National Coordinator for Health Information Technology (ONC) showing proof of certified EHR technology is required, which is how the Indiana Medicaid EHR Incentive Program confirms that your EHR technology is acceptable. Just be sure to include the new system information in all future attestations after a change is made.

  • Can healthcare professionals working in behavioral health settings participate in the Indiana Medicaid PI Program?

    Eligibility is based on provider type, not on practice location. (See response to "What are the eligibility requirements for eligible professionals?" question for a list of eligible professionals.)

  • Are physician assistants eligible for the Indiana Medicaid PI Program?

    There are very limited situations in which a physician assistant would be eligible for the Indiana Medicaid PI Program. For more information, please contact the Indiana Medicaid PI Help Desk at (317) 488-5137 or 1-855-856-9563; or send your inquiry to MedicaidHealthIT@fssa.in.gov.

  • If I am not eligible for the Indiana Medicaid PI Program, is there another way I might receive incentive payments?

    Yes. You could be eligible to participate in the Medicare PI Program. Check the Medicare eligibility guidelines on the CMS website at cms.gov to see if you qualify.

Attestation

Patient Volume

  • How does Indiana define a "patient encounter"?

    For eligible professionals, a "patient encounter" is defined as a single service, per day, per patient, when Medicaid paid for all or part of the service, including an individual's premium, copayment, or cost-sharing.

    For eligible hospitals, an encounter is defined as a service rendered to an individual in one of the following ways:

    • Per inpatient discharge
    • On any one day in the emergency room when Indiana Medicaid or another state's Medicaid program paid for:
      • Part or all of the service
      • Part or all of their premiums, copayments, or cost-sharing
  • What is the minimum Medicaid patient volume threshold to be eligible for the Indiana Medicaid PI Program?

    As eligible professionals (EPs), pediatricians need a minimum of 20% Medicaid patient volume. All other EPs need a minimum of 30% Medicaid patient volume.

    Eligible hospitals must have a minimum Medicaid patient volume of 10%, except for children's hospitals, which have no Medicaid patient volume requirement.

  • How is Medicaid patient volume calculated?

    The following formula is used to determine Medicaid patient volume for eligible professionals:

    Medicaid Patient Volume Formula for Eligible Professionals = Medicaid patient encounters
    (over a continuous 90-day period from the preceding calendar year [CY])

    divided by

    Total patient encounters
    (during the same continuous 90-day period from the preceding CY)

    Indiana uses the following formula to determine Medicaid patient volume for eligible hospitals:

    Medicaid Patient Volume Formula for Eligible Hospitals = Medicaid discharges + other Medicaid discharges
    (over a continuous 90-day period from the preceding CY)

    divided by

    Total discharges all lines of business
    (during the same continuous 90-day period from the preceding CY)

  • Can zero-pay claims be included in our Medicaid patient volume calculation?

    Yes, if the services were provided to a beneficiary who is enrolled in Medicaid.

  • Can I include Children's Health Insurance Plan (CHIP) claims in my Medicaid patient volume calculation?

    You can include CHIP Package A members in your patient volume calculation, but not CHIP Package C members. Currently, 2.52% of IHCP members are on CHIP Package C. If you are unsure of your CHIP patient volume, you will need to apply a 2.52% reduction to the numerator when entering the patient volume numbers to account for CHIP Package C members (except for federally qualified health centers or rural health clinics; see the "What are the eligibility requirements for eligible professionals?" question under Eligibility).

  • How do attesting as an individual practitioner, a group/clinic, or a practitioner panel differ?

    When you choose to attest as an individual practitioner, you use only that practitioner's patient volume numbers.

    If you choose to attest as a group/clinic, you will report the group's/clinic's patient volume numbers instead of the individual practitioner's patient volume numbers. A practice may choose to attest as a group in scenarios where not all the practitioners are able to meet the minimum patient volume threshold individually, based on their patient payer mix, but can meet the threshold as a group. Keep in mind that if you choose the group/clinic patient volume option, the following requirements must be met:

    • The group/clinic must have a minimum Medicaid patient volume of 30%.
    • All EPs in the group must use the same attestation methodology for the payment year. (In other words, the group/clinic cannot have some of the EPs in the group attesting as individual practitioners using their individual patient volume numbers, while other EPs attest as a group/clinic using the group's/clinic's patient volume numbers.)
    • The group/clinic proxy must include patient encounters from all practitioners in the group/clinic, regardless of whether all practitioners are Medicaid providers. The group's/clinic's Medicaid patient volume calculation cannot be limited in any way and must include all provider types (physicians, nurse practitioners, therapists, and so on) that submit claims within that group/clinic.
       

    The practitioner panel option is for practitioners that practice in a managed care or medical home setting. The PI FAQs on the CMS website provide more information about the requirements associated with attesting under the practitioner panel option and calculating the related Medicaid patient volume.

  • What are the patient volume requirements for EPs who practice predominantly at federally qualified health centers and rural health clinics?

    A Medicaid EP is considered to be practicing predominantly in a federally qualified health center or rural health clinic when the clinical location for more than 50% of the EP's total patient encounters over a period of six months within the prior calendar year (or preceding 12-month period from the date of attestation) is at a federally qualified health center or rural health clinic. EPs that fall in this category must have a minimum of 30% of their patient volume attributable to needy individuals.

    "Needy individuals" are individuals that meet one of the following criteria:

    • Received medical assistance from Medicaid or the Children's Health Insurance Program (CHIP) or a Medicaid or CHIP demonstration project approved under section 1115 of the Social Security Act
    • 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
       

    The EP enters the numerator and denominator as detailed in the "How is Medicaid patient volume calculated?" question to calculate the "needy individual" patient volume.

  • I have selected the locations on the patient volume page in MAPIR (page 3 of 3) but am unable to move past this section.

    If you are using EHR technology only at certain locations (for which you select "Yes"), you must select "No" at the other locations. Otherwise, the system will not allow you to advance.

Post-Attestation

  • How will I know if additional information is needed to process the attestation?

    An Indiana Medicaid PI Program analyst will review your application and contact you if any further information is needed to process the attestation.

  • When will I receive my payment?

    It will take approximately 3 weeks to receive payment after the attestation application is successfully submitted. If an application is submitted near the end of a quarter (March, June, September, December), it could take an additional 1 to 2 weeks to process the payment because of how funds are released by CMS to the State. Attestations submitted near critical deadlines (see the "What are the deadlines for completing attestations?" question under Attestation) could take an additional 2 to 4 weeks to process due to increased attestation volume.

  • How will I receive my payment?

    Generally, an electronic fund transfer (EFT) is made to the person or entity associated with the "Payee NPI" in the applicant's CMS registration. However, if the payee is not set up for EFT, a check is cut and sent to the payee address. If the incentive payment is made via EFT, the payment will show on the payee's Remittance Advice as "Non-Claim Specific Payouts to Providers."

  • How much money will an eligible professional (EP) receive?

    The following table indicates the amount of payment EPs will receive during their participation in the program. Please note: Pediatricians will receive less incentive money than shown on the chart due to lower Medicaid patient volume threshold requirements.

    Medicaid Incentive Payment Schedule
      CY 2011 CY 2012 CY 2013 CY 2014 CY 2015 CY 2016
    CY 2011 $21,250          
    CY 2012 $8,500          
    CY 2013 $8,500 $8,500 $21,250      
    CY 2014 $8,500 $8,500 $8,500 $21,250    
    CY 2015 $8,500 $8,500 $8,500 $8,500 $21,250  
    CY 2016 $8,500 $8,500 $8,500 $8,500 $8,500 $21,250
    CY 2017   $8,500 $8,500 $8,500 $8,500 $8,500
    CY 2018     $8,500 $8,500 $8,500 $8,500
    CY 2019       $8,500 $8,500 $8,500
    CY 2020         $8,500 $8,500
    CY 2021           $8,500
    Total $63,750 $63,750 $63,750 $63,750 $63,750 $63,750

     

  • Does Indiana apply payment adjustments for eligible professionals (EPs) and eligible hospitals (EHs) not demonstrating meaningful use?

    No. There are no payment adjustments or penalties for EPs or EHs participating in the Indiana Medicaid PI Program. However, participation in the Indiana Medicaid PI Program does not affect payment adjustments made by Medicare. Beginning in 2015, practices and hospitals that see Medicare patients are required to demonstrate meaningful use or be subject to a payment adjustment. For example, if a Medicare or Medicaid practice or hospital attests to adoption, implementation, or upgrade (AIU) with the Indiana Medicaid PI Program in 2015, that practice or hospital would be subject to payment adjustments with Medicare.

Audits

  • How will I know if I am selected for a PI Program Adopt, Implement, Upgrade (AIU) or PI (formerly MU) audit?

    All AIU audits are performed via a desk review, and the audit team reviews all submitted documentation to determine if any additional documentation is required to complete the review. Because of this approach, eligible professionals (EPs) and eligible hospitals (EHs) selected for an AIU audit are not notified before the audit, with the exception of requests for additional information from the provider that may be needed to complete the audit. Providers selected for an AIU audit are notified of audit findings via letter.

    EPs and EHs selected for PI audits are notified via certified letter, as these audits can be performed via desk or on-site reviews, and auditors request detailed documentation from the providers to support the PI attestation.

  • When are on-site audits performed?

    As required by CMS, Indiana performs a percentage of EHR audits on site, based on a CMS-approved selection process. On-site audits are also performed as determined by audit staff, and are based on desk review results or other internal factors. All providers selected for on-site audits are notified before the audit.

  • What type of information will be requested for the audit?

    General information requested from providers during an audit can include, but is not limited to, the following.

    For eligible professionals (EPs):

    • Documentation to confirm a provider's relationship with the EHR vendor, such as a contract or financial obligation document
    • Documentation to support providers' affiliation with a practice that attests as a group
    • Detailed information to support the patient volume numerator and denominator used for the reporting period
    • Documentation to support an EP's affiliation with multiple locations if patient volume is reported for multiple locations
    • Documentation supporting that at least 80% of all unique patients have their data in the certified electronic health record technology (CEHRT) and that at least 50% of all encounters occur in a location where CEHRT is used
    • Meaningful use core, menu, and clinical quality measure reports for the reporting period used in the attestation that originate from the CEHRT
    • Documentation to support all meaningful use measures that do not require a numerator and denominator
       

    For eligible hospitals (EHs):

    • Detailed information supporting the Medicaid patient volume calculation
    • Detailed information supporting the payment calculation
    • Meaningful use core, menu, and clinical quality measure reports for the reporting period used in the attestation that originate from the CEHRT
    • Documentation to support all meaningful use measures that do not require a numerator and denominator
  • If the information I need to provide to meet the audit request contains PHI, is it against HIPAA regulations to respond to the audit request?

    No, it is not a violation of HIPAA to respond to the State's request for documentation in response to an audit. The HIPAA Privacy Rule specifically addresses an exception for the release of PHI in the case of audits and investigations necessary for overseeing the healthcare system and government benefit programs. The relevant section of the rule summary (from page 7 of the Health Oversight Activities section of the summary of the Privacy Rule) follows: Health Oversight Activities. Covered entities may disclose protected health information to health oversight agencies (as defined in the Rule) for purposes of legally authorized health oversight activities, such as audits and investigations necessary for oversight of the health care system and government benefit programs.

    See the complete Summary of the HIPAA Privacy Rule at the U.S. Department of Health and Human Services website at hhs.gov.

    It is important to remember that data containing PHI should be submitted electronically only using secured technology in accordance with your firm's HIPAA policy. The state or its audit contractor can provide a secure method to submit this information electronically. Information relating to the secure submission of electronic records is included in the audit document request correspondence.

    Other sensitive information may also be requested, such as payer source (Medicare, Medicaid, or other) and amount paid. As no information regarding the patient's procedure (procedure codes or descriptions) or insurance carrier (name) is requested, the amount reported could not be used to identify a specific procedure or insurance carrier, and, therefore, no contractually sensitive information is obtained through these audits.

    It is also important to note that the audit process is required by CMS, and the numerator and denominator must be validated through this process. Auditors request the least amount of information necessary to accomplish a CMS-compliant review.

  • Whom do I contact if I have questions about the information requested during the audit?

    If providers have questions about the information requested in the audit letter, they should refer to the contact information in the audit letter.

  • Can I be audited more than once?

    Yes. All EPs and EHs are subject to an audit every year they participate in the Indiana Medicaid PI Program.

  • How are providers selected for audits?

    The Indiana audit team retrieves a list of all providers paid during the audit period from the Indiana attestation system, MAPIR. Paid claims data is queried for each provider that received a payment. The results of these queries are compared to the providers' attestations and prepayment review results. As a result, each provider is placed in one of four risk categories, based on the criteria. From each category, auditors select sample sizes to be audited.

  • When will I know the results of my audit?

    Providers are notified of the status of their audits via letter. Time frames can vary based on the complexity of the documentation reviews.

  • If I am an eligible professional (EP), what can I expect from an on-site audit?

    An on-site audit typically consists of two parts:

    • The first part of the audit helps the audit team gain an understanding of how the EHR system is used in the EP's workflow. Auditors understand the EHR system through discussions with people knowledgeable about the system and the data entry that occurs during the EP's normal workflow. Later, testing is designed to validate the EP's use of the system, at which point the presence of the EP is typically not necessary. If questions that only the EP can answer arise during the process, the EP is typically allowed to respond at a subsequent time that is more convenient for the EP.
    • The second part of the audit allows the audit team the opportunity to perform a detailed review of documentation and source information. Before auditors arrive, they request detailed information from a sample of the attested measures; after arriving, auditors perform analytical procedures and confirm the information in the EHR system on-site.
       

    The auditors arrange the visit and request any additional information, as necessary, before they arrive. The time required for on-site visits varies depending on the number of EPs being reviewed and the provider's familiarity with the EHR system.

  • What is a draft audit finding?

    Providers receive a draft audit finding when the preliminary review of the attestation identifies a potential failure to meet all program requirements. Providers are notified of draft audit findings via certified mail and are given an opportunity to request administrative reconsideration within 45 days from the date of the letter. Failure to request timely administrative reconsideration results in a forfeit of the provider's right to appeal, and the preliminary calculation of overpayment is finalized.

  • What is a final calculation of overpayment?

    A provider receives a final calculation of overpayment when, after administrative reconsideration, the provider fails to meet program requirements; or when the provider forfeits his or her right to appeal by failing to request timely administrative reconsideration, as detailed in his or her draft audit finding letter.

  • What is a final audit finding?

    If there are no audit findings after the attestation review is complete, the provider receives a letter of final audit findings advising that all program requirements have been satisfactorily met.

  • How do I respond to audit findings?

    Letters of draft audit findings and final calculation of overpayments will outline information regarding how providers may respond.

  • When are PI incentive payment funds recouped if an overpayment is identified?

    Indiana law requires that providers repay the amount of the final calculation within 300 days of receiving the final calculation of overpayment letter, regardless of whether providers are eligible for or choose to appeal the determination (IC 12-15-13-3.5(e)). Failure to repay within 300 calendar days results in recoupment of the amount due against current claims. It is important to note that the Patient Protection and Affordable Care Act (H.R. 3590) § 6402(a) imposes new obligations on Medicaid providers, suppliers, and health plans to report and return overpayments within 60 days of the date the overpayment was identified.

  • Can I appeal a draft audit finding?

    No. Before filing an appeal, providers must request administrative reconsideration, as detailed in the draft audit findings letter.

  • What is administrative reconsideration?

    Providers can request administrative reconsideration if they receive a draft audit finding. Providers can submit, along with their request for administrative reconsideration, comments and supporting documentation for the audit team to consider before making a final determination.

    For example, if a provider receives a draft audit finding that a preliminary review of his or her EHR application and attestation has resulted in a potential overpayment because of the provider's failure to meet the required 30% Medicaid patient volume, the provider can request administrative reconsideration. That request must be made within 45 days of the date of the draft audit findings letter. In the administrative reconsideration request, the provider might include comments and documentation that support the required 30% Medicaid patient volume for the period for which the provider attested.

    The audit team reviews these comments and documentation. After the audit team's administrative reconsideration review, the provider receives a letter from the Family and Social Services Administration (FSSA) that is a final calculation of overpayment, if the audit team still believes an overpayment exists; or a final audit findings letter, if the audit team determines that no overpayment exists.

  • Can I appeal a final calculation of overpayment?

    Yes. If the provider disagrees with the final calculation of overpayment and wishes to appeal the FSSA's determination, the provider must request a hearing by filing a written administrative appeal request within 60 calendar days of his or her receipt of the notice of final calculation of overpayment. Detailed instructions are contained in the final calculation of overpayment letter.

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