Eligible Professionals - Eligibility Rules

To qualify for an incentive payment under the Medicaid 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 EHR Incentive Program, a provider must meet the following requirements:

  1. Licensed to practice in Wisconsin, Wisconsin Medicaid enrolled, has no current or pending sanctions, and is 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 an FQHC/RHC that is so led by a physician assistant.

  1. Is not hospital based - must have less than 90% of Medicaid covered services, rendered during the calendar year preceding the payment year, occurring in an inpatient (POS 21) or emergency department setting (POS 23), or demonstrate that they have funded the acquisition, implementation and maintenance of CEHRT without reimbursement from an Eligible Hospital or CAH – and use such CEHRT at a hospital, in lieu of using the hospital’s CEHRT.
  2. Meet patient volume requirements.

For further explanation of eligibility requirements see the Eligible Professionals FAQ (PDF, 610 KB)

Patient Volume

Eligible Professionals must meet at least 30% Medicaid Patient Volume (20% for pediatricians) calculated at the individual provider 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 by their total patient encounters (regardless of payer) for a consecutive 90-day period. For purposes of calculating patient volume, an encounter is defined as the services rendered on any one day to an individual. 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 the provider. A Medicaid encounter is defined as services rendered on any one day to an individual enrolled in a Medicaid program, regardless of claim amount paid by Medicaid.

Standard Deduction

Since Wisconsin ForwardHealth includes both Medicaid and CHIP funding, Eligible Professionals do not have a way of knowing which funding streams cover their patients. The federal rule around the Medicaid EHR Incentive Program does not allow encounters paid by CHIP to be counted as part of the Medicaid Patient Volume, unless the patient is seen at a Federally Qualified Health Center (FQHC) or Rural Health Center (RHC). To reduce this barrier, the Wisconsin Medicaid Agency annually calculates a standard percentage of CHIP beneficiaries to be subtracted from the total Medicaid and BadgerCare+ beneficiary encounters. Eligible Professionals must use the Standard Deduction to remove their CHIP volume when calculating patient volume.

The Standard Deduction for Program Year 2015 is 7.07%.

Patient Volume Reporting Time

Eligible Professionals calculate their patient volume 90-day eligibility period within one of the following time periods:

  • Calendar year preceding Payment Year
  • 12 months preceding attestation date

Note: Attestation date will be defined as the day when the application is electronically signed and submitted for the first time in the Program Year or the last day of the Program Year if 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 on a group-level. This means the encounters for all practitioners (eligible and non-eligible providers) in a group practice are used to determine patient volume.

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% patient volume attributable to "needy individuals" to be eligible for the 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 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 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% 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 EHR Incentive 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, 257 KB) , in the State Medicaid Health Information Technology Plan (SMHP).

Last Revised: August 13, 2015