Eligible Professionals - Eligibility Rules

To qualify for an incentive payment under the Wisconsin Medicaid Promoting Interoperability Program, formerly known as the Electronic Health Record (EHR) Incentive Program, an Eligible Professional must meet certain eligibility criteria. For more information on these requirements, please refer to the information below.

Eligibility Rules

In order to qualify for the Wisconsin Medicaid Promoting Interoperability Program, a provider must:

  1. Be licensed to practice in Wisconsin, be Medicaid enrolled, have no current or pending sanctions, and be one of the following provider types:
  • Physician (Provider Type 31)
  • Dentist (Provider Type 27)
  • Certified nurse midwife (Provider Type 16)
  • Advanced practice nurse prescriber (Provider Type 11)
  • Nurse practitioner (Provider Type 09)
  • Physician assistant (Provider Type 10)

Note: A physician assistant must practice in a federally qualified health center (FQHC) or a rural health clinic (RHC) that is led by a physician assistant.

Note: To be eligible for an incentive payment a provider must be enrolled in Wisconsin Medicaid as a billing/rendering provider on the date their Wisconsin Medicaid Promoting Interoperability application is submitted and on the date the incentive payment is issued. If the provider’s Medicaid enrollment has lapsed or terminated they cannot receive the incentive payment.

  1. Have less than 90 percent of services occurring in an inpatient (place of service [POS] code 21) or emergency department (POS code 23) setting, or demonstrate that they have funded the acquisition, implementation, and maintenance of CEHRT without reimbursement from an Eligible Hospital or Critical Access Hospital – and they use such CEHRT at a hospital, in lieu of using the hospital’s CEHRT.
  2. Meet patient volume requirements.
  3. Have participated in the Medicaid Promoting Interoperability Program prior to program year 2017.

For further explanation of eligibility requirements see the Eligible Professionals FAQ (PDF).

Patient Volume

Eligible Professionals must meet at least 30 percent Medicaid patient volume (20 percent for pediatricians) calculated at the individual provider level or the group practice level. To understand additional patient volume requirements, carefully read each of the sections below. You can also watch the Introduction to Eligible Professional Patient Volume Webinar for information on how to calculate Medicaid patient volume.

Medicaid Patient Volume

Patient volume is calculated by dividing an Eligible Professional’s Medicaid patient encounters (with the standard deduction applied) by his or her total patient encounters (regardless of payer) for a consecutive 90-day period.

For purposes of calculating patient volume, an encounter encompasses all services rendered to an individual on any one day. Only one encounter can be counted for a patient per day per provider, regardless of the number of services provided to the patient in a single day by that provider.

A Medicaid encounter encompasses all services rendered on any one day to an individual enrolled in a Medicaid program, regardless of the Medicaid reimbursement amount. Unpaid encounters for services rendered to an individual enrolled in a Medicaid program may be counted as eligible Medicaid encounters. Claims denied because the patient was not Medicaid eligible at the time of service cannot be counted as Medicaid encounters.

Standard Deduction

Since ForwardHealth is funded by both Medicaid and the Children’s Health Insurance Program (CHIP), Eligible Professionals do not have a way of knowing which funding streams cover their patients. However, the federal rule around the Medicaid Promoting Interoperability Program does not allow encounters paid by CHIP to be counted as part of the Medicaid patient volume, unless the patient is seen at an FQHC or RHC. To address this discrepancy, the Wisconsin Medicaid Promoting Interoperability Program annually calculates a standard percentage of CHIP encounters to be subtracted from the total Medicaid and BadgerCare Plus beneficiary encounters.

Eligible Professionals must use this standard deduction to remove their CHIP encounters when calculating Medicaid patient encounters.

The standard deduction for Program Year 2020 is 4.41 percent.

Patient Volume Reporting Period

One of the following time periods is used by Eligible Professionals to calculate their patient volume 90-day eligibility period:

  • The calendar year preceding the Payment Year.
  • The 12 months preceding the attestation date.

Note: The attestation date is the date that the application is electronically signed and submitted for the first time in the Program Year, or the last day of the Program Year if the Eligible Professional is applying during the grace period.

Group/Clinic Patient Volume Option

If a provider is part of a practice or clinic, the patient volume may be calculated using the encounters for all practitioners (eligible and non-eligible providers) in the group practice.

In order to use the group practice patient volume calculation, an Eligible Professional is required to have at least one encounter with an eligible member during the patient volume reporting period. This encounter does not need to be funded by Wisconsin Medicaid and does not need to occur at the current group practice. If the Eligible Professional is new to practicing medicine (e.g., a recent graduate of an appropriate training program), he or she does not need to provide proof of an encounter.

Needy Individuals Patient Volume Option

Providers that practice predominantly in an FQHC or RHC may use "needy individuals" in the patient volume calculation. Eligible Professionals practicing in an FQHC or RHC must have at least 30 percent patient volume attributable to "needy individuals" to be eligible for the Medicaid Promoting Interoperability Program. "Needy individuals" are defined in Section 1903(t)(3)(F) of the Social Security Act as individuals meeting any of the following three criteria:

  • They are receiving medical assistance from Wisconsin Medicaid or CHIP.
  • They are given uncompensated care by the provider.
  • They are provided services at either no cost or reduced cost based on a sliding scale determined by the individual’s ability to pay.

Note: The term “practice predominantly” is defined as providing 50 percent or more of services in an FQHC or RHC during a six-month period in the previous calendar year or during the 12 months preceding the attestation date.

Global Billing Patient Encounter Clarification

When calculating patient volume, Eligible Professionals can count both individually billed and globally billed events as encounters as long as medical treatment and/or evaluation and management services are provided. Eligible Professionals should clearly document how globally billed encounters were derived in their patient volume calculations. Eligible Professionals are encouraged to upload this documentation as a part of their Wisconsin Medicaid Promoting Interoperability Program application in order to avoid delays in the review of the application.

For more information on patient volume methodology, refer to Appendix A: Patient Volume (PDF), in the State Medicaid Health Information Technology Plan (SMHP).

Last Revised: July 27, 2020