Am I Eligible?

Determine Your Eligibility

The first step in Promoting Interoperability Program enrollment is determining eligibility.  There are numerous resources available to assist in determining your eligibility. They are:

Eligibility Questions

Your responses to the questions below will help determine your eligibility:

Eligible Professional (EP)

Have you signed a contract, purchased or installed an ONC Certified Electronic Health Record System?

In any 90 consecutive days during the preceding calendar year or twelve months prior to the attestation date, did you or your practice have at least 30% of your patient encounters paid by HFS? Or 30% of patient encounters across one or multiple practices paid by HFS (>=20% for Pediatricians)? This percentage is also known as Medicaid Utilization.

Are more than 10% of your services performed outside of a hospital setting (Services billed as (Place of Service Code 21) or emergency room (Place of Service Code 23))?

Are you one of the provider types below, with a currently active Illinois Medicaid enrollment and in good standing with HFS?

  • Physician

  • Nurse Practitioner

  • Certified nurse-midwife

  • Dentist

  • Optometrist

  • Physician assistant who furnishes services in a Federally Qualified Health Center of Rural Health Clinic that is led by a physician assistant.

If you answered YES to any of the above, you may be eligible for the Medicaid Incentive Payment. You are encouraged to use Federal CMS�s Eligibility tool to further determine if you are eligible.

Eligible Hospitals

  1. Have you signed a contract, purchased or installed an ONC Certified Electronic Health Record System?
  2. In any 90 days during the preceding Federal Fiscal year or previous 12 months, did the hospital have at least 10% of its patient encounters paid by HFS?
  3. Are the last four digits of the hospital�s CMS Certification Number (CCN) in the range 0001-0879 or 1300-1399?

If you answered YES to all of the questions above, you may be eligible for the Medicaid and additionally, the Medicare Incentive Payment. You are encouraged to use Federal CMS�s Eligibility tool to further determine if you are eligible.  

Establishing Patient Volume

One key aspect of eligibility is patient volume. To qualify for an incentive payment under the Illinois Promoting Interoperability Program, an eligible professional must meet one of the following criteria for Medicaid patient volume:

  • Have a minimum 30% Medicaid patient volume

  • Have a minimum 20% Medicaid patient volume, and be a pediatrician; for the purposes of the Illinois Promoting Interoperability Program, a pediatrician is defined as:

    • A Medicaid enrolled provider who serves 90% of patients under the age of 21 based on the age of the patient at the time the service is rendered

 or

    • A Medicaid enrolled provider with a valid, unrestricted medical license and board certification in Pediatrics through either the ABP or the AOBP

    • Practice predominantly in a Federally Qualified Health Center or Rural Health Center and have a minimum 30% patient volume attributable to needy individuals

To calculate Medicaid patient volume, an EH must divide:

  • The total HFS Medicaid encounters and out-of-state Medicaid encounters in any representative 90-day period in the preceding fiscal year or twelve (12) months preceding attestation by:

  • The total encounters in the same 90-day period.

    • Total number of inpatient discharges in the representative 90-day period plus total number of emergency department visits in the same 90-day period. 

    • Note that the emergency department must be part of the hospital.

Types of Encounters to Report as Medicaid Encounters

Eligible Professional (EP)

  • Title XIX and Title XXI (Due to transparency initiatives, providers cannot determine the difference between encounters billed for Title XIX Medicaid and Title XXI programs. The numerator must consist of all encounters billed to HFS as Title XIX + Title XXI ).

  • MCO Encounters

  • Dual Eligible (Medicare/Medicaid)

EP Practicing Predominantly* in an FQHC/RHC

  • Title XIX (Medicaid)

  • MCO Encounters

  • Dual Eligible (Medicare/Medicaid)

  • Needy Individuals � must meet one of the following criteria:

  • Received medical assistance from Medicaid (Title XIX) or SCHIP (Title XXI)

  • Were furnished uncompensated care by the provider (Charity Care)

  • Were furnished services at either no cost or reduced cost based on a sliding scale determined by the individual's ability to pay (Sliding Fee Scale)

*For this program, practicing predominantly in an FQHC/RHC means 50% or more of the total patient volume for the EP over a six-month period is at an FQHC/RHC

Group Practices

Clinics or group practices will be permitted to calculate patient volume at the group practice/clinic level only in accordance with all of the following limitations:

  • The clinic or group practice's patient volume is appropriate as a patient volume methodology calculation for the EP

  • There is an auditable data source to support the clinic's or group practice's patient volume determination

  • All EPs in the group practice or clinic must use the same methodology for the payment year

  • The clinic or group practice uses the entire practice or clinic's patient volume and does not limit patient volume in any way

  • If an EP works inside and outside of the clinic or practice, then the patient volume calculation includes only those encounters associated with the clinic or group practice, and not the EP's outside encounters.

For purposes of calculating eligible hospital patient volume, a Medicaid encounter is defined as services rendered to an individual 1) per inpatient discharge, or 2) on any one day in the emergency room where HFS paid for:

  • Part or all of the service

  • Part or all of their premiums, co-payments, and/or cost-sharing

Exception � a children�s hospital is not required to meet Medicaid patient volume requirements.

Payment Prerequisites

The items listed below can prohibit a provider from receiving an incentive payment. Please ensure you have met the prerequisites below:

  1. The Provider must be enrolled as an HFS provider and in good standing with the department.
    1. For enrollment information, visit the Provider Enrollment section of the HFS Medical Programs website.
  2. The payee tax identification number (TIN) designated during registration at the CMS Registration and Attestation Web site must represent a valid certified payee on file with HFS for the provider completing the attestation.
    1. Providers can verify the payee TIN by reviewing their Provider Information Sheet. Corrections can either be made at the Federal CMS Registration and Attestation website by changing to a certified payee listed on their Provider Information Sheet or by contacting the Bureau of Comprehensive Health Services, Provider Participation Unit at 217-782-0538 for further assistance.
  3. The Provider or hospital must be an eligible provider type to participate in the Illinois Promoting Interoperability Program, which include:

EP Type and Specialty

Physician

Physician Assistant (practicing in a FQHC or RHC led by a Physician Assistant): An FQHC or RHC is considered to be PA led in the following instances:

    • The PA is the primary provider in a clinic (e.g., part time physician and full time PA in the clinic)

    • The PA is the clinical or medical director at a clinical site of the practice

    • The PA is the owner of the RHC

Pediatrician: Any provider who is Board Certified as a Pediatrician or has at least 90% of Medicaid Recipients Under the Age of 21. 

    • Nurse Practitioner

    • Certified Nurse Midwife

    • Dentist

    • Optometrist

EH Type and Specialty

  • Acute Care Hospital

  • Children�s Hospital

  • Critical Access Hospital

Once providers have ensured that all necessary prerequisites have been met, they may proceed with Registration and Attestation.

Step 2 � Register with CMS


Promoting Interoperability Program for Medicaid (eMIPP)

 

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