Eligible Professionals - Attestation

To receive a Wisconsin Medicaid Promoting Interoperability Program payment, Eligible Professionals must attest to the adoption, implementation, upgrade or Meaningful Use of CEHRT. Meaningful Use is the standard by which providers demonstrate the use of CEHRT in ways that can positively affect the care of patients. To meet meaningful use requirements and receive an incentive payment, providers must meet a set number of objectives and measures established by the Centers for Medicare and Medicaid Services (CMS) for the Medicaid Promoting Interoperability Program. More detailed information is provided below.

Certified EHR Technology

Before an Eligible Professional can attest to meeting Promoting Interoperability Program requirements, he or she must acquire or have access to CEHRT. In Program Year 2019 and subsequent program years, all Eligible Professionals are required to use technology certified to the 2015 Edition.

For more information on CEHRT, including how to obtain the CMS EHR Certification ID used during registration and the Wisconsin incentive application process, please refer to the Certified Health IT Product List.

Adopt, Implement, Upgrade

Eligible Professionals participating in their first year did not have to attest to Meaningful Use criteria; rather, they could demonstrate that they adopted, implemented, or upgraded CEHRT:

  • Adopt: Eligible Professionals must demonstrate acquisition, installation, or contractual proof of an acquisition or future acquisition of CEHRT in the first payment year.

  • Implement: Eligible Professionals must meet the criteria for adopting CEHRT and demonstrate actual implementation, installation, or utilization of CEHRT.

  • Upgrade: Eligible Professionals must meet the criteria for adopting and implementing, and demonstrate expansion of, CEHRT functionality such as the addition of an e-prescribing functionality or computerized physician order entry.

Note: Beginning in Program Year 2017, Eligible Professionals may no longer attest to the adopt, implement or upgrade phase.

Meaningful Use

Participation Timeline

The last year for an Eligible Professional to initiate participation in the Medicaid Promoting Interoperability Program is 2016. Calendar Year 2021 is the last year a participant may receive an incentive payment.

The criteria for Meaningful Use are staged in three steps over the course of the program:

  • Stage 1 sets the baseline for electronic data capture and information sharing.

  • Stage 2 and Modified Stage 2 advance clinical processes.
    CMS established a modified set of criteria for attestation in Program Years 2015 through 2018, known as Modified Stage 2. Modified Stage 2 replaced the core and menu structure of Stages 1 and 2 with a single set of objectives and measures, and establishes several other changes to the EHR Incentive Program.

  • Stage 3 improves outcomes.

In Program Year 2019 and beyond, Eligible Professionals must attest to Stage 3 of Meaningful Use.

EHR Reporting Period for Meaningful Use

In Program Year 2019, the EHR reporting period for Eligible Professionals is any continuous 90 days between January 1, 2019, and December 31, 2019.

Note: Eligible Professionals are not required to attest in consecutive years and may attest to the AIU phase and then a 90-day EHR reporting period in a subsequent year of participation.

Stage 3 Meaningful Use

The requirements for Stage 3 contain eight objectives for Eligible Professionals, including one consolidated public health reporting objective.

Eligible Professionals will attest to all eight objectives by either meeting the measure(s) or satisfying an exclusion, if applicable. Eligible Professionals may choose to satisfy an exclusion, rather than meet the measure, when the measure is not applicable to them and they meet the exclusion criteria.

Stage 3 includes flexibility within certain objectives to allow Eligible Professionals to choose the measures most relevant to their patient population or practice. The Stage 3 objectives with flexible measure options include:

  • Coordination of Care through Patient Engagement – Eligible Professionals must attest to all three measures and must either meet the thresholds or satisfy an exclusion for at least two measures to meet the objective.
  • Health Information Exchange – Eligible Professionals must attest to all three measures and must either meet the thresholds or satisfy an exclusion for at least two measures to meet the objective.
  • Public Health Reporting – Eligible Professionals must either meet or satisfy an exclusion for two measures. More information is detailed in the section below.

For more information on the Eligible Professional Stage 3 requirements for Program Year 2019, review the Eligible Professional Meaningful Use Specification Sheets.

Process for Reporting Public Health Objectives

All Eligible Professionals, regardless of their stage of Meaningful Use, are required to register with the Wisconsin Department of Health Services (DHS), Division of Public Health (DPH), to initiate an onboarding process for the public health report objective. For current registration information, Eligible Professionals should refer to the Public Health Meaningful Use website.

Electronic Clinical Quality Measures (eCQMs)

In addition to meeting the Meaningful Use measures, Eligible Professionals are also required to report on eCQMs. Although eCQMs are reported separately from Meaningful Use measures, all Eligible Professionals are still required to report eCQMs in order to demonstrate Meaningful Use.

All Eligible Professionals, regardless of their stage of Meaningful Use, are required to report on six of the available eCQMs. Of the six, one must be an "outcome" measure. If no outcome measures are relevant to the provider’s scope of practice, then the provider must report on one "high-priority" eCQM. If no outcome or high-priority eCQMs are relevant to the Eligible Professional’s scope of practice, the Eligible Professional must report on any six eCQMs. See the Wisconsin High-Priority Electronic Clinical Quality Measures (P-012315) document for more information on the available outcome and high-priority eCQMs.

Zero is an acceptable value for the eCQM denominator, numerator, and exclusion fields and will not prevent you from demonstrating Meaningful Use or receiving an incentive payment. Eligible Professionals can meet the eCQM requirements even if one or more eCQMs have “0” in the denominator, provided that this value was produced by CEHRT.

See the CMS Clinical Quality Measure Basics page on the CMS website to learn more about reporting eCQMs. For a complete listing of available eCQMs, refer to the Electronic Clinical Quality Improvement (eCQI) Resource Center.

Electronic Clinical Quality Measure (eCQM) Reporting Periods

The following date ranges are the eCQM reporting periods for Meaningful Use for Program Year 2019:

  • The eCQM reporting period for Eligible Professionals who are attesting to Meaningful Use criteria for the first time is any continuous 90-day period between January 1, 2019 and December 31, 2019. 
  • The eCQM reporting period for Eligible Professionals who have successfully demonstrated any stage of Meaningful use in a prior year, is the full calendar year from January 1, 2019 through December 31, 2019.

Note: In prior years, the reporting period for eCQMs was the same as the Meaningful Use EHR reporting period for that Program Year. The policy for Program Year 2019 is different because Eligible Professionals who have successfully demonstrated any stage of Meaningful use in a prior year have an eCQM reporting period of a full calendar year and an EHR reporting period of only 90-days.

Attestation Supporting Documentation

All information is subject to audit at any time and must be maintained by Eligible Professionals for a period of six years. If selected for an audit, the applicant must be able to supply supporting documentation. A failed audit may result in a recoupment of incentive payments. Refer to the Appeals Process topic (topic #12137) in the Promoting Interoperability Program section of the ForwardHealth Online Handbook for Physicians for a table that contains examples of supporting documentation an Eligible Professional would be expected to provide if selected for an audit.

ONC Questions

Beginning in 2017, CMS requires Eligible Professionals to attest to Objective 0, which contains a series of questions about cooperation with the following policies:

  • Demonstration of supporting information exchange and prevention of information blocking.
  • Demonstration of good faith with a request relating to Office of the National Coordinator for Health Information Technology (ONC) direct review of CEHRT.

The Objective 0 Tip sheet was developed to help you understand this requirement prior to attestation.

Last Revised: September 25, 2019