Eligible Professionals - Required Documentation

Beginning in Program Year 2017, all Eligible Professionals are required to submit documentation to support Meaningful Use measure data. Read the Meaningful Use Measure Documentation Requirements section below for details.


Eligible Professionals are required to attest to meeting all program requirements when completing an application, including program eligibility criteria and volume requirements. Eligible Professionals must submit documentation to support their attestation in addition to the information entered directly into the ForwardHealth application (regardless of their year of participation in the program).

The Wisconsin Medicaid EHR Incentive Program has received guidance from CMS to securely collect supporting documentation pre-payment in an effort to avoid fraud, waste, and abuse. This guidance also states that the Wisconsin Medicaid EHR Incentive Program has the right to access information for program administration and payment purposes covered under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Wisconsin Medicaid strongly encourages all Eligible Professionals to upload their supporting documentation directly to their application and also reminds participants that they must retain supporting documentation for the Wisconsin Medicaid EHR Incentive Program application in their files for six years after their attestation has been completed. For specific instructions on how to upload documentation, Eligible Professionals should refer to the Wisconsin Medicaid Electronic Health Record Incentive Program User Guide for Eligible Professionals.

Required documentation includes:

  • Certified EHR Technology Documentation
  • Patient Volume Documentation
  • Meaningful Use Measure Documentation (new in Program Year 2017)

Certified EHR Technology Documentation Requirements

All Eligible Professionals must submit at least one of the following documents to support the acquisition or use of 2014 or 2015 Edition CEHRT:

  • Contract
  • Lease
  • Proof of purchase
  • Receipt
  • Signed vendor letter

All of the following must be identified on the submitted CEHRT documentation, regardless of format:

  • Vendor
  • Product
  • Product version number
  • Indication that CEHRT was adopted, implemented, upgraded, or in use during the Program Year for which the provider is applying

Submission Requirements

All documentation must be either uploaded to the Wisconsin Medicaid EHR Incentive Program application or emailed to the Wisconsin Medicaid EHR Incentive Program. Follow the directions below to understand which submission options are available for you.

Eligible Professionals attesting on their own behalf, are required to upload CEHRT documentation to the Wisconsin Medicaid EHR Incentive Program application.

Any practice attesting on behalf of more than one Eligible Professional may upload their supporting documentation to each application or may submit the CEHRT documentation for all of the Eligible Professionals via one secure email. To submit via email:

  1. Identify the organization name to which the documentation is applicable within the body of the email, to ensure documentation is applied to the appropriate application.
  2. Encrypt all confidential information.
  3. Attach the CEHRT documentation to the email.
  4. Indicate the following as the subject line of the email: “Eligible Professional Application Supporting Documentation.”
  5.  Attach all other required documentation to the email before sending it to the Wisconsin Medicaid EHR Incentive Program.

Eligible Professionals are encouraged to send all documentation in a single email and encrypt all confidential information.

Patient Volume Documentation Requirements

Please note the documentation requirements do not affect how Eligible Professionals calculate individual or group practice patient volume for the Wisconsin Medicaid EHR Incentive Program. Read each section below for more information:

Eligible Professionals Reporting Individual Patient Volume

All Eligible Professionals reporting individual patient volume are required to submit a copy of the detail report used to calculate their patient volume.

The detail report must include the following information:

  • National Provider Identifier (NPI).
  • The following details regarding each reported eligible patient encounter (an eligible patient encounter is defined as any services rendered on any one day):
    • Date of service
    • Unique patient identifier (e.g., Medicaid ID, patient name)*
    • Financial payer (e.g., Medicaid fee-for-service, managed care, commercial health insurer, Medicare) or an indication that the encounter is considered a Medicaid encounter
    • Out-of-state Medicaid encounters (e.g. name of the state), if applicable
    • Indication that the encounter is considered an "other needy" encounter (e.g., the service was provided at no cost or on a sliding fee scale); this is only applicable if needy individual patient volume is reported.

Note: The unique patient identifier must be either a Medicaid ID or patient name if the encounter is counted as a Medicaid encounter. Alternative patient identifiers may be used for all non-Medicaid encounters (e.g., Medical Record Number, Patient Control Number, etc.)

Eligible patient encounter details should support both the patient volume numerator (before the standard deduction, if applicable) and denominator entered in the Wisconsin Medicaid EHR Incentive Program application.

Eligible Professionals Reporting Group Practice Patient Volume

Eligible Professionals attesting to group practice patient volume will be required to submit (1) the summary report of the provider information included in the group practice patient volume calculation and (2) the detail report used to enter their patient volume substantiating the information provided in the summary. Organizations using the group patient volume calculation for more than one Eligible Professional application will submit the same detail and summary report for each application. This means that the summary and detail reports will not vary from one application to another for the same group NPI.

The summary report must include the following information for each provider included in the group practice patient volume calculation:

  • Provider name
  • Provider NPI
  • Individual Medicaid encounter volume (numerator) and total encounter volume (denominator) for each provider included in the group practice patient volume calculation

The detail report must include the following information:

  • Group and provider NPIs.
  • The following details regarding each reported patient encounter (a patient encounter is defined as any services rendered on any one day):
    • Date of service
    • Unique patient identifier (e.g., Medicaid ID, patient name)*
    • Financial payer (e.g., Medicaid fee-for-service, managed care, commercial health insurer, Medicare) or an indication that the encounter is consider a Medicaid encounter
    • Out-of-state Medicaid encounters (e.g., name of the state), if applicable
    • Indication that the encounter is considered an “other needy” encounter (e.g., the service was provided at no cost or on a sliding fee scale); this is only applicable if needy individual patient volume is reported.

Note: The unique patient identifier must be either a Medicaid ID or patient name if the encounter is counted as a Medicaid encounter. Alternative patient identifiers may be used for all non-Medicaid encounters (e.g., Medical Record Number, Patient Control Number, etc.)

Patient encounter details should support both the patient volume numerator (before the standard deduction, if applicable) and denominator entered in the Wisconsin Medicaid EHR Incentive Program application. Alternative supporting documentation may be submitted for an Eligible Professional if the Eligible Professional has no claims with his or her current group practice during the 90-day patient volume reporting period because he or she is are either new to practicing medicine (e.g., a recent graduate of an appropriate training program) or reporting at least one encounter with an eligible member from a previous practice.

Submission Requirements

All documentation must be either uploaded to the Wisconsin Medicaid EHR Incentive Program application or emailed to the Wisconsin Medicaid EHR Incentive Program. Follow the directions below to understand which submission options are available for you.

Eligible Professionals attesting on their own behalf, are required to upload their supporting documentation to the Wisconsin Medicaid EHR Incentive Program application.

Any practice attesting on behalf of more than one Eligible Professional may submit the patient volume documentation for all of the Eligible Professionals via one secure email. To submit via email:

  1. The individual patient volume detail report should be named: “Patient Volume_<Eligible Professional NPI>” to ensure documentation is applied to the appropriate application.
  2. Encrypt all confidential information.
  3. Attach the detail report(s) to the email.
  4. Indicate the following as the subject line of the email: “Eligible Professional Application Supporting Documentation.”
  5. Attach all other required documentation to the email before sending it to the Wisconsin Medicaid EHR Incentive Program.

Eligible Professionals are encouraged to send all documentation in a single email and encrypt all confidential information.

Meaningful Use Measure Documentation Requirements

Beginning in Program Year 2017, all Eligible Professionals are required to submit documentation to support Meaningful Use measure data. Meaningful Use documentation submission has been optional in prior Program Years, but is now required.

Eligible Professionals are required to submit security risk analysis (SRA) documentation and Meaningful Use reports for percentage-based measures to demonstrate requirements were met for Meaningful Use measures during the 90-day electronic health record (EHR) reporting period selected. Read each section below for more information:

Security Risk Analysis (SRA) Documentation

Eligible Professionals are required to submit SRA documentation, to support Objective 1, Protect Patient Health Information. The SRA must be completed prior to December 31, 2017. For groups, practices may provide one SRA for all of their Eligible Professionals.

Supply detail on SRA including:

  • Approach for assessment
  • Results of the assessment
  • Indication of who performed the assessment

Supply detail on security update performed as a result of the SRA including, but not limited to:

  • Update made
  • Date made

Meaningful Use Reports

Eligible Professionals are required to submit Meaningful Use report(s) to support all Meaningful Use percentage-based measures (with numerators and denominators). Applicable percentage-based measures include:

Modified Stage 2 Stage 3
  • Objective 3: Computerized Provider Order Entry, Measures 1-3
  • Objective 4: Electronic Prescribing, Measure 1
  • Objective 5: Health Information Exchange, Measure 1
  • Objective 6: Patient-Specific Education, Measure 1
  • Objective 7: Medication Reconciliation, Measure 1
  • Objective 8: Patient Electronic Access, Measures 1 and 2
  • Objective 9: Secure Electronic Messaging, Measure 1
  • Objective 2: Electronic Prescribing, Measure 1
  • Objective 4: Computerized Provider Order Entry, Measures 1-3
  • Objective 5: Patient Electronic Access to Health Information, Measures 1 and 2
  • Objective 6: Coordination of Care through Patient Engagement, Measures 1-3
  • Objective 7: Health Information Exchange, Measure 1-3

All EHRs should electronically record the numerator and denominator and generate a report that includes the numerator, denominator, and percentage, which may be used to enter data into the Attestation section of the application. If the Meaningful Use reports do not support the exact data entered in the Attestation section of the application, Eligible Professionals may also submit any other source material used to enter the Meaningful Use measure numerators and denominators.

This type of documentation can be used for:

  • Percentage-based measures
  • Any claimed exclusions where the report displays a “0” for the denominator or the report displays a denominator that is less than a threshold specified in the measure exclusion criteria. (For example, if the requirement states that an exclusion may be used by an Eligible Professional with “less than 100 orders” and the report supports that the Eligible Professional had less than 100 orders.)

Note: At this time, Eligible Professionals are not required to submit documentation supporting their Clinical Quality Measures (CQMs).

Submission Requirements

All documentation must be either uploaded to the Wisconsin Medicaid EHR Incentive Program application or emailed to the Wisconsin Medicaid EHR Incentive Program. Follow the directions below to understand which submission options are available for you.

If the Eligible Professional is attesting on his or her own behalf, he or she is required to upload supporting documentation to his or her Wisconsin Medicaid EHR Incentive Program application.

Any practice attesting on behalf of more than one Eligible Professional may submit the Meaningful Use measure documentation for all of the Eligible Professionals via one secure email. To submit via email:

  1. Securely attach all required supporting documentation to the email.
  2. Indicate the following as the subject line of the e-mail: "Eligible Professional Application Supporting Documentation."
  3. Identify the organization name to which the SRA documentation is applicable if submitting SRA documentation for more than one Eligible Professional.
  4. Submit all the reports in a single email if submitting Meaningful Use reports for more than one Eligible Professional. Each Meaningful Use report file should be named, “MU Dashboard_<Eligible Professional NPI>,” to ensure the documentation is applied to the appropriate application. If multiple reports are contained in a single file, the Eligible Professional’s name and/or NPI must be clearly identified on the report to ensure it is applied to the appropriate application.
  5. Send the email to the Wisconsin Medicaid EHR Incentive Program.

Eligible Professionals are encouraged to send all documentation in a single email and encrypt all confidential information.

Last Revised: August 23, 2017