Eligible Professionals, Eligible Provider, Provider Payment, Patient Volume, Medicaid Payment

Eligible Professionals (EP) Types include: Physicians, Nurse Practitioners, Certified Nurse Midwives, Dentists, Physician Assistants

Topics found
on this page:

Eligible Professional Types

Medicaid Patient Volume

Hospital-Based Practitioners

Practicing Predominantly in a FQHC/RHC
and the Needy Patient Volume



Eligible Professionals: Program Eligibility

For a healthcare practitioner to be eligible to receive an incentive payment with the NY Medicaid EHR Incentive Program, the provider must meet all program eligibility requirements. In addition to the information found on this webpage, healthcare practitioners can attend the live eligible professional(EP) webinars (look for EP labeled webinars on the schedule) to find answers to any questions about the NY Medicaid EHR Incentive Program and program eligibility requirements. To view the monthly webinar schedule please click here.


Eligible Professionals (EP) Types

The following types of healthcare practitioners are eligible to apply for the NY Medicaid EHR Incentive Program:

*Pediatricians have the reduced option of demonstrating 20-30% Medicaid patient volume, but will only receive 2/3 the incentive payment when their percentage is below 30%.


For more specifics on eligible professional types, please refer to the following FAQs: Frequently Asked Question Location
Eligible Professional Types EP01
NYS Pediatrician Definition EP28



Medicaid Patient Volume

Eligible Professionals (EP) who enroll in the Medicaid EHR Incentive Program must demonstrate each year that at least 30% of their patient volume is attributed to Medicaid during a 90 day reporting period they choose (see section below for more details). EPs must also attest to the Medicaid patient volume requirement by attesting to either the standard or alternative patient volume methods in the Medicaid EHR Incentive Payment Administrative Support Service (MEIPASS). Additionally, EP in groups have an option to combine the totals of all EPs in the group and attest using aggregate totals, and there is assistance available for those who have difficulty assembling their Medicaid Patient Volume.

 
Medicaid encounter types which can be counted toward both methods: Type of ServiceMedicaid Encounter
Medicaid Fee-For-Service
Medicaid Managed Care
Family Health Plus

Standard Patient Volume Method (Recommended)

NY Medicaid's recommended approach for EPs is to attest to the Medicaid patient volume using the standard Medicaid patient volume. Using this method, an EP counts the number of Medicaid-enrolled patient encounters during the 90 day reporting period, and divides that number by the total number of patient encounters over the same period.

Total Medicaid Encounters ÷
(divided by)
Total Encounters

Alternate Patient Volume Method

NY Medicaid provides an alternative approach for those EPs with significant managed care populations. NY Medicaid recommends the EP first try using the standard patient volume method; if the EP cannot meet the 30% Medicaid threshold, then the EP should try this alternative calculation:

Total Medicaid Patients*
assigned to the practitioner in any representative continuous 90 day period in the preceding calendar year, with at least one encounter in the 24 months preceding the start of the 90 day period  
+ Unduplicated Medicaid encounters*
in that same 90 day period
÷
(divided by)
Total Patients
assigned to the practitioner in the same 90 day period with at least one encounter in the 24 months preceding the start of the 90 day period
+ All Unduplicated encounters
in that same 90 day period


*Note that this same equation applies to making a determination for Needy Individual patient volume, where "Medicaid" is substituted by "Needy Individuals."

In this calculation, "unduplicated" simply means that an EP may not include the same encounters more than once. There may be multiple encounters with patients (even with patients included on the panel), but these may not be counted in more than one place in the equation. In addition, as noted in the preamble of the July 28, 2010 Federal Register (page 44488), the "unduplicated encounters" would only be encounters with non-panel Medicaid patients that occurred during the representative 90 day period.

Aggregate Medicaid Patient Volume

Eligible Professionals (EP) in a group practice or clinic may use the practice or clinic's aggregate patient volume as a proxy for their individual Medicaid patient volume, subject to the following restrictions:

  1. To take advantage of this option, all EPs in the practice or clinic (regardless of how much of their overall practice volume is within the practice or clinic) must use the group numbers (i.e., if one EP uses the group's aggregate numbers, another EP in the practice may not use his/her individual values, and vice-versa).
  2. EPs for whom the aggregate patient volume is not an appropriate proxy (i.e., providers who exclusively see Medicare or self-pay patients) may NOT use the aggregate patient volume.
  3. Aggregate values must represent the entire practice or clinic's patient volume and not limit it in any way (including not limiting it to only patients seen by EPs).

A group opting to use the aggregate patient volume may use either the standard or the alternative method (as described above) for calculating patient volume.

For further information regarding the use of Aggregate Medicaid Patient Volume, please call the NY Medicaid EHR Incentive Program Support Help Desk at 1-877-646-5410, Option 2 or email HIT@health.ny.gov

90 Day Reporting Period Guidance

Payment Years 2011-2012

This patient volume reporting period must be entirely within the calendar year (CY) prior to the payment year and it must be "representative" of the provider's overall practice, but otherwise each EP is free to select any 90 consecutive days as the patient volume reporting period.

Payment Year 2013 and beyond

This patient volume reporting period must any consecutive 90 day period within the calendar year (CY) prior to the payment year or preceding 12 month period from the date of the attestation*. The patient volume recorded within this 90 day period must be "representative" of the provider's overall practice.

*Expanded Reporting Period Disclaimer: Please be aware that it may take an additional 90 days to validate your attestation if you select a 90 day reporting period up to the date of attestation.

Medicaid Encounter Summary Request

Some providers have indicated an inability to calculate the number of Medicaid patient encounters - most commonly due to a lack of insight into which managed care patients are Medicaid beneficiaries. The NYS Department of Health has developed a process allowing providers to request a summary of fee-for-service claims and managed care encounters submitted under their NPI. If you would like to request a summary of fee-for-service claims and managed care encounters for the year prior to the participation year, please email HIT@health.ny.gov.

For additional information about the Medicaid patient volume, please call the NY Medicaid EHR Incentive Program Support Help Desk at 1-877-646-5410.

For more information on the Medicaid Patient Volume, please refer to the following FAQs: Frequently Asked Question Location
Medicaid Patient Volume & Patient Volume Period EP06
Medicaid Patient Encounters EP07
Group Patient Volume EP05
Group Provider Definition EP19
Group Patient Volume and NPI EP20
Multiple Group and Patient Volume EP21
Out-of-State Encounters EP34



Hospital-Based Practitioners

To be eligible to receive the NY Medicaid EHR Incentive, the healthcare practitioner must not be "hospital-based." Hospital-based practitioners are defined by CMS as those practitioners who furnish 90% or more of their covered professional (i.e., Medicaid) services in the hospital inpatient and emergency department (defined as services that would be identified using place of service (POS) codes 21 and 23 on HIPAA-standard transactions).

Note: This percentage is based on the entire calendar year prior to the payment year.

Frequently Asked Question Location
Hospital-based Exclusion EP22
Hospital-based Documentation EP80



Practicing Predominantly in a FQHC / RHC, and the Needy Patient Volume

Eligible professionals (EP) who practice predominantly in a Federally Qualified Health Center (FQHC) or Rural Health Center (RHC) are eligible to use the Needy Patient Volume calculation to meet the Medicaid patient volume requirement. The Needy Patient Volume allows an EP to add three additional encounter types to the numerator of the patient volume calculation and follows the same guidelines as the Medicaid patient volume. The EPs must attest to the Needy patient volume requirement by attesting to the standard or alternative patient volume methods in MEIPASS.

Needy encounters that can be counted toward the Needy patient volume are as follows: Type of ServiceNeedy Encounter
Medicaid Fee-For-Service
Medicaid Managed Care
Family Health Plus
Child Health Plus
Uncompensated Care
Sliding Scale

For more information regarding working predominantly in an FQHC / RHC and Needy patient Volume, please refer to the following FAQs: Frequently Asked Question Location
Practice Predominantly Definition EP29
FQHC / RHC Definition EP29
Needy Patient Encounter EP07
Practice Predominantly Requirement EP32




What's Next?

Learn about the Program Prerequisites next

For Further Assistance

Please utilize the support resources by clicking on Support, found at the bottom of every page in the EHR Incentive Program website to address any questions you may have regarding the NY Medicaid EHR Incentive Program.