Eligible Professionals - Attestation

To receive a Wisconsin Medicaid EHR Incentive 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 EHR Incentive Program. More detailed information is provided below.

Certified EHR Technology

Before an Eligible Professional can attest to meeting EHR Incentive Program requirements, he or she must acquire or have access to  CEHRT.

  • In Program Year 2017, Eligible Professionals can choose to use technology certified to the 2014 Edition, the 2015 Edition, or a combination of the two editions.
  • In Program Year 2018, Eligible Professionals can choose to use technology certified to the 2014 Edition, the 2015 Edition, or a combination of the two editions.
  • In Program Year 2019 and subsequent Program Years, all Eligible Professionals are required to use technology certified to the 2015 Edition.

    Note: If attesting to Stage 3 requirements, Eligible professionals must use technology certified to the 2015 Edition. An Eligible Professional who has technology certified to a combination of the 2015 Edition and 2014 Edition may potentially attest to the Stage 3 requirements, if the mix of certified technologies would not prohibit them from meeting the Stage 3 measures. An Eligible Professional who has technology certified to the 2014 Edition only, may not attest to Stage 3.

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 do not have to attest to Meaningful Use criteria; rather, they may demonstrate that they have 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 EHR Incentive 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 advances clinical processes.
    CMS established a modified set of criteria for attestation in Program Years 2015 through 2017, known as Modified Stage 2. Modified Stage 2 replaces 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.

The table below indicates what stage of Meaningful Use must be reported based on the first year an Eligible Professional began participation in the Wisconsin Medicaid EHR Incentive Program. It is assumed that an Eligible Professional’s first year of participation is the AIU phase and his or her participation occurs in consecutive years; however, Eligible Professionals may participate in non-consecutive Program Years and may attest to Meaningful Use the first year of participation.

First Year of Participation (AIU)
Stage of Meaningful Use by Program Year
2017 and 2018*
2019+
2011
Modified Stage 2 or Stage 3 Stage 3
2012
Modified Stage 2 or Stage 3 Stage 3
2013
Modified Stage 2 or Stage 3 Stage 3
2014
Modified Stage 2 or Stage 3 Stage 3
2015
Modified Stage 2 or Stage 3 Stage 3
2016
Modified Stage 2 or Stage 3 Stage 3

* In August 2017, a CMS final rule changed federal requirements to allow Eligible Professionals the choice of attesting to Modified Stage 2 in Program Year 2018.

EHR Reporting Period for Meaningful Use

The following date ranges are the EHR reporting periods for Meaningful Use in Program Year 2017, 2018, and beyond:

  • In Program Year 2017, the EHR reporting period for Eligible Professionals is any continuous 90 days between January 1, 2017, and December 31, 2017.
  • In Program Year 2018, the EHR reporting period for Eligible Professionals is any continuous 90 days between January 1, 2018, and December 31, 2018.
  • In Program Year 2019 and subsequent Program Years, all Eligible Professionals, except new meaningful users, will be allowed to select any continuous 90-day period as from January 1 through December 31 of the calander year as their EHR reporting period.

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.

Modified Stage 2 Meaningful Use

The requirements for Modified Stage 2 contain 10 objectives for Eligible Professionals, including one consolidated public health reporting objective.

Each objective has one or more measures to which the Eligible Professional are required to attest. Eligible Professionals will attest to all 10 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.

For more information on the Eligible Professional Modified Stage 2 requirements for Program Year 2017, review the Eligible Professional 2017 Meaningful Use Specification Sheets.

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 2017, review the Eligible Professional 2017 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.

Clinical Quality Measures (CQMs)

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

All Eligible Professionals, regardless of their stage of Meaningful Use, are required to report on six of the 53 available CQMs. (Note: In August 2017, a CMS final rule aligned the specific CQMs available in the Medicaid EHR Incentive Program with those available in the Merit-based Incentive Payment System. This change removed 11 CQMs and the requirement that selected CQMs must cover at least three of the six available National Quality Strategy domains.)

Zero is an acceptable value for the CQM denominator, numerator, and exclusion fields and will not prevent you from demonstrating Meaningful Use or receiving an incentive payment. Eligible Professionals can meet the CQM requirements even if one or more CQMs 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 CQMs. For a complete listing of available CQMs, refer to the eCQM Library on the CMS website. Wisconsin Medicaid recommends Eligible Professionals report on the priority CQMs identified in Attachment 2.

CQM Reporting Periods

For Program Year 2017, the CQM reporting period for all Eligible Professionals is any continuous 90-day period between January 1, 2017, and December 31, 2017.

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. Refer to the EHR Incentive Program section of the ForwardHealth Online Handbook 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 now requires Eligible Professionals to attest to a series of questions to demonstrate 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.
Last Revised: September 8, 2017