Subsection 144-101-I-2.04 - ELIGIBLE PROFESSIONALA. An Eligible Professional must meet the requirements established in 42 C.F.R. §495.304(c) unless exempt under 42 C.F.R. §495.304(d).Title 42 C.F.R.§§ 495.310(a) through (e) governs payments to EPs.B.Medicaid or Needy Individual threshold requirements Table 1 lists the minimum percentage of Medicaid or Needy Individual encounters for each type of Professional for this Program. See Title 42 C.F.R. §495.304(c).
Types of Professionals that may apply for the incentive payment program | Minimum Medicaid or Needy Individual encounters |
Physician, certified nurse-midwife, nurse practitioner, dentist | 30% Medicaid encounters |
Pediatrician | 20% Medicaid encounters |
Physician, certified nurse-midwife, nurse practitioner, or a dentist who practices predominantly in an FQHC or RHC | 30% Needy Individual encounters |
Physician assistant who practices predominantly in an FQHC or RHC that is led by a physician assistant | 30% Needy Individual Encounters |
C.Application Process for EPs1. A Professional must register with CMS through the CMS National Level Repository (NLR) system.2. After a Professional registers, CMS sends an electronic notification to OMS of the registration.3. Using the contact information from the NLR registration, OMS will contact the Professional to begin the application process.4. A Professional must establish that he or she is an EP and meet the following requirements: a. Using the encounter method, establish that he or she has met the minimum Medicaid patient volume required under 42 C.F.R. §495.304(c)(1), or practices predominantly in a Federally Qualified Health Center (FQHC) or in a Rural Health Clinic (RHC) and has met the minimum Needy Individual volume under 42 C.F.R. §495.304(c); andb. Attest that he or she has adopted, implemented or upgraded electronic health records to be eligible for the first payment year, or that he or she has met Meaningful Use requirements under the applicable stage to be eligible for subsequent payment years; andc. Attest that he or she uses an EHR that is included on the list of certified EHRs maintained by CMS; andd. Attest that he or she has not received an incentive payment for that year from another state; ande. Attest that he or she has not received an incentive payment under the Medicare incentive payment program for that year; andf. Satisfactorily complete the application process; andg. Meet the meaningful use reporting requirement set forth under 42 C.F.R. §495.312(b).5. After confirming that the Professional meets the requirements enumerated in this section 2.04, MaineCare will notify CMS that a payment is being issued, and will issue a payment to the EP according to the requirements of 42 C.F.R. §495.312(e)(1).6. If the Department determines that a Professional has not met the requirements of this Section 2.04, it will notify the Professional in writing within two (2) business days of making that determination.D.Payment Amounts and ScheduleA Professional who meets EP status requirements for all six years is eligible to receive a total of $63,750 in payments issued as follows:
1. A first year payment of $21,250; except that a pediatrician who has between 20% and 30% Medicaid encounters is limited to a maximum first year payment of $14,167.2. For years two through six, a payment of $8,500 for each year that the EP meets the requirements for that year; except that a pediatrician who has between 20% and 30% Medicaid encounters is limited for years two through six to a payment of $5,667 for each year.3. A payment will be issued to the EP unless the EP reassigns his or her incentive payment pursuant to 42 C.F.R §495.310(k)(1).E. Attestation and Meaningful Use DocumentationA Professional must have written or electronic documentation that the Professional meets all of the EP requirements for the Program and the incentive payment(s).
1. As proof of adopting, implementing or upgrading a certified electronic health record, the EP must have at least one of the following properly executed documents: 2. In accord with 42 C.F.R. §495.8(c)(2), any records used to provide information for registration, application or incentive payments, including attestation that the Professional has adopted, implemented or upgraded EHR, and meaningful use, must be kept for six years, unless Federal or State law requires a longer retention period. 2.04-1COMBATING FRAUD AND ABUSEA. An EP must submit an electronic or paper statement supplied by the Department in satisfaction of the requirements of 42 C.F.R. §495.368(b).B. If an overpayment is owed to the Department, the EP shall repay the entire overpayment within thirty (30) days of the date of the Department's notice to the EP of the overpayment.C. EPs are subject to the provisions of the MaineCare Benefits Manual, Chapter 1, Sections 1.12, 1.19 and 1.20 in regard to incentive payments.D. The Division of Audit or duly authorized Agents of the Department shall conduct pre-payment reviews and must approve all payments before issuance. The Division of Audit or duly authorized Agent shall have the authority to conduct post-payment audits to include desk and on-site audits under the Department's SMHP and IAPD-U and Chapter 1, Section 1, §1.16. 2.04-2HEARINGS AND APPEALSA. An EP may appeal the following issues: 1. A determination that the Professional is not eligible for the HIT Incentive Payment Program;2. A determination that the Professional did not meet attestations of adopting, implementing or upgrading certified EHRs or Meaningful Use of EHR requirements;3. An overpayment amount or recoupment as determined by the Department or CMS; and4. Audit findings of any of the above.B. Appeal rights and processes are governed by MaineCare Benefits Manual, Chapter 1, Section 1, §1.21-1. C.M.R. 10, 144, ch. 101, ch. I, § 144-101-I-2, subsec. 144-101-I-2.04