Chapter 5101:3-57 Medicaid Provider Incentive Program

5101:3-57-01 Medicaid provider incentive program (MPIP): eligible providers and patient volume requirements.

(A) The medicaid provider incentive program (MPIP) is Ohio's program for implementing section 4201 of the American Recovery and Reinvestment Act of 2009 (ARRA), Pub. L. No. 111-5, and the published regulations at 42 C.F.R. Part 495 (as in effect on July 28, 2010) that establish a program that permits certain eligible professionals and eligible hospitals participating in medicaid programs to receive incentive payments if they are meaningful users of certified electronic health records (EHR) technology. The incentive payments are not a reimbursement, but are intended to encourage eligible professionals and eligible hospitals to adopt, implement, or upgrade certified EHR technology and use it in a meaningful manner. MPIP incentive payments will only be made as long as federal funds are available.

(B) The following medicaid providers are eligible to participate in MPIP:

(1) Medicaid eligible professionals; and

(2) Medicaid eligible hospitals.

(1) An eligible professional is limited to the following types of providers, consistent with the scope of practice as it is recognized under Ohio law as applicable for each type of professional:

(a) Physicians, including optometrists, in accordance with rule 5101:3-4-01 of the Administrative Code.

(b) Dentist.

(d) Nurse practitioners.

(e) Physician assistants (PA) practicing in a federally qualified health center (FQHC) or a rural health center (RHC) that is so led by a PA. "So led" means the PA is the primary provider in a clinic (for example, when there is a part-time physician and the PA is full-time, the PA will be considered as the primary provider); the PA is a clinical or medicaid director at a clinical site or practice; or the PA is an owner of an RHC.

(2) An eligible professional must, for each year of participation in MPIP:

(a) Be an enrolled Ohio medicaid provider with an active Ohio medicaid provider agreement.

(b) Not be hospital-based.

(i) An eligible professional is considered hospital-based if ninety per cent or more of the eligible professional's medicaid encounters are furnished in an inpatient hospital (place of service code (POS) 21) or an emergency room (POS 23) setting in the calendar year (CY) prior to the payment year.

(ii) The hospital-based exclusion does not apply to a medicaid eligible professional qualifying as practicing predominantly through a FQHC or RHC as defined in paragraph (C)(4)(c) of this rule.

(i) Another state;

(ii) MPIP; or

(iii) The medicare EHR incentive payment program.

(3) An eligible professional must not have a current sanction or exclusion identified at:

(a) The United States department of health and human services, office of inspector general, list of excluded individuals and entities: or

(b) The Ohio list of excluded providers.

(4) An eligible professional must meet one of the following patient volume criteria:

(a) Have a minimum patient volume of thirty per cent attributable to individuals whose medical services delivered were eligible for and reimbursed by medicaid.

(b) Have a minimum patient volume of twenty per cent attributable to individuals whose medical services delivered were eligible for and reimbursed by medicaid if the provider is a pediatrician.

(i) For purposes of MPIP only, a pediatrician means a medical doctor, who diagnoses, treats, examines, and prevents diseases and injuries in children. A pediatrician must hold a doctor of medicine (MD) or doctor of osteopathy (DO) degree and hold a current, in good-standing board certification in pediatrics through the American board of pediatrics, the American board of surgery, the American board of radiology, the American board of urology or the American osteopathic board of pediatrics.

(c) Practice predominantly through a FQHC or RHC and have a minimum thirty per cent patient volume attributable to needy individual encounters (as defined in paragraph (F)(3) of this rule). An eligible professional practices predominantly through an FQHC or RHC if the clinical location for over fifty per cent of his or her total patient encounters over a period of six months in the most recent CY occurs through an FQHC or an RHC.

(D) Medicaid eligible hospitals.

(1) An eligible hospital must be one of the following:

(a) An acute care hospital where the average length of stay is twenty-five days or fewer (acute care hospital's average length of stay will be calculated based on the hospital's fiscal year); and has a federal centers for medicare and medicaid services (CMS) certification number that has the last four digits in the series 0001-0879 or 1300-1399.

(b) Cancer hospitals and critical access hospitals are included in the definition of an acute care hospital and will be eligible for MPIP if they meet the requirements under an acute care hospital described in this rule.

(c) A children's hospital that is separately certified and is either freestanding or a hospital-within-a hospital that has a CMS certification number with the last four digits in the series 3300-3399 and predominantly treats individuals under the age of twenty-one.

(2) An eligible hospital must be an enrolled Ohio medicaid provider with an active Ohio medicaid provider agreement.

(3) An eligible hospital may be dually eligible for both the medicare EHR incentive payment program and MPIP if it meets all of the following criteria:

(a) Is a sub-section(d) hospital in the fifty United States or the District of Columbia, as defined in section 1886(d)(1)(B) of the Social Security Act (2010), 42 U.S.C. 1395ww; and

(b) Has a CMS certification number ending in 0001-0879;

(4) An eligible hospital must not have received a medicaid EHR incentive payment, within the current payment year, from:

(a) Another state; or

(b) MPIP.

(5) An eligible hospital must not have a current sanction or exclusion identified at:

(a) The United States department of health and human services, office of inspector general, list of excluded individuals and entities; or

(b) The Ohio list of excluded providers.

(6) An eligible hospital must meet a minimum patient volume of ten per cent attributable to those individuals whose medical services delivered were eligible for and reimbursed by medicaid. A children's hospital is exempt from meeting a patient volume threshold.

(E) Establishing patient volume.

(1) Patient volume is calculated in accordance with the patient encounter methodology defined in 42 C.F.R. 495.306(c) (as in effect on July 28, 2010).

(2) To calculate patient volume, an eligible professional must divide:

(a) The total medicaid patient encounters (fee-for-service and managed care) in any continuous ninety-day period, beginning on the first day of a month, in the preceding CY; by (b) The total patient encounters in the same ninety-day period.

(3) To calculate needy individual patient volume, an eligible professional must divide:

(a) The total needy individual patient encounters in any continuous ninety-day period, beginning on the first day of a month, in the preceding CY; by

(b) The total patient encounters in the same ninety-day period.

(4) To calculate patient volume, an eligible hospital must divide:

(a) The total medicaid patient encounters (fee-for-service and managed care) in any continuous ninety-day period, beginning on the first day of a month, in the preceding federal fiscal year (FFY); by

(b) The total encounters in the same ninety-day period.

(F) Encounters.

(1) Encounters are defined in accordance with 42 C.F.R. 495.306(e) (as in effect on July 28, 2010).

(2) For purposes of calculating eligible professional patient volume, a medicaid encounter means services rendered to an individual on any one day where medicaid (fee-for-service and managed care):

(a) Paid for part or all of the service; or

(b) Paid for part or all of the individual's premiums, co-payments, and cost sharing.

(3) For purposes of calculating needy individual patient volume, a needy patient encounter means services rendered to an individual on any one day where:

(a) Medicaid (including the state children's health insurance program (SCHIP)) paid for part or all of the service; or

(b) Medicaid (including SCHIP) paid for part or all of the individual's premiums, co-payments, and cost-sharing; or

(c) Services were furnished at no cost; and calculated as being uncompensated or charity care. If an eligible professionals's data are not available on charity care, then the eligible professional may use data on uncompensated care and must include a downward adjustment to eliminate bad debt (as defined in 42 C.F.R. 413.89, as in effect on October 1, 2004); or

(d) The services were paid for at a reduced cost based on a sliding scale and determined by the individual's ability to pay.

(4) For purposes of calculating eligible hospital patient volume, a medicaid encounter means both of the following:

(a) Services rendered to an individual per inpatient discharge where medicaid (fee-for-service and managed care):

(i) Paid for part or all of the service; or

(ii) Paid for part or all of the individual's premiums, co-payments, and cost sharing.

(b) Services rendered in an emergency department on any one day where medicaid (fee-for-service and managed care):

(i) Paid for part or all of the service; or

(ii) Paid for part or all of the individual's premiums, co-payments, and cost sharing.

(5) Out-of-state encounters.

(a) An eligible professional and eligible hospital may use out-of-state medicaid encounters for calculating patient volume.

(b) "Out-of-state encounters" are services rendered by an eligible professional or eligible hospital to a non-Ohio resident that meets the definitions of an encounter as defined in paragraph (F) of this rule.

(c) If out-of-state medicaid encounters are included in the numerator then all out-of-state encounters, for the same representative time period, should be included in the denominator.

(d) Eligible professionals and eligible hospitals are required to provide documentation to support the use of out-of-state encounters and must report each state's out-of-state encounters separately through the MPIP system, in a manner specified by the Ohio department of job and family services (ODJFS).

(G) Group practice or clinic patient volume proxy.

(1) A group practice or clinic will be permitted to calculate patient volume at the group practice or clinic level, but only in accordance with all of the following limitations defined in 42 C.F.R. 495.306(h) (as in effect on July 28, 2010):

(a) The group practice or clinic's patient volume is appropriate as a patient volume methodology calculation for the eligible professional.

(b) There is an auditable data source to support the group practice's or clinic's patient volume determination.

(d) The group practice or clinic must use the entire practice's or clinic's patient volume and not limit patient volume in any way.

(e) If an eligible professional works inside and outside of the group practice or clinic, the patient volume calculation includes only those encounters associated with the group practice or clinic, and not the eligible professional's outside encounters.

(2) To calculate patient volume at the group practice or clinic level, all medicaid eligible professionals, (as defined in paragraph (C) of this rule), of the group practice or clinic must:

(a) Have a valid, current Ohio medicaid provider agreement; and

(b) Have rendered and billed medicaid for at least one medicaid covered service with a date of service in the ninety-day period associated with the calculation of patient volume, and has been reimbursed for that service.

(3) Each group practice or clinic must confirm in writing, in a manner specified by the ODJFS, from each eligible professional in the group practice or clinic, that the eligible professional is consenting to one of the following:

(a) Attesting as a member of the group practice or clinic and permitting the group practice or clinic to use his or her encounters in the group practice or clinic patient volume proxy calculation; or

(b) Not attesting as a member of the group practice or clinic but will permit the group practice or clinic to use his or her encounters in the group practice or clinic patient volume proxy calculation.

(4) Evidence of an eligible professional's consent must be provided for processing through the MPIP system and must include the following information:

(a) The group practice or clinic name and medicaid ID number;

(b) The name and medicaid ID number of each eligible professional in the group; and

(c) Must specify if each eligible professional is consenting to the use of his or her encounters as defined in paragraphs (G)(3)(a) and (G)(3)(b) of this rule.

(5) If an eligible professional is not attesting as a member of a group practice or clinic but will permit a group practice or clinic to use his or her encounters in the patient volume proxy calculation for the group practice or clinic, the non-participating eligible professional cannot use those encounters toward his or her individual patient volume calculation.

(6) If any eligible professional within the group practice or clinic does not provide written consent for the group practice or clinic to use his or her encounters in the patient volume proxy calculation for the group practice of clinic, the group practice or clinic is precluded from using a group practice or clinic patient volume proxy.

(7) Supporting documentation must be provided for processing through the MPIP system of the attested patient volume proxy and include the medicaid encounters, total encounters, name and medicaid ID of all medicaid practitioners used in the group practice or clinic patient volume proxy calculation. This information shall be provided in a manner specified by ODJFS.

(8) Eligible professionals must be employed by the group practice or clinic at the time of attestation in order to use the group practice's or clinic's patient volume proxy.

(H) SCHIP adjustment.

(1) Eligible professionals (except for eligible professionals practicing predominantly through a FQHC/RHC) and eligible hospitals (except for children's hospitals) in counties with children covered by virtue of Title XXI of the Social Security Act, will be subject to a federally required SCHIP adjustment to patient volume. This adjustment is a reduction equal to the value of the lesser of the average statewide per cent of children covered by virtue of Title XXI or by the per cent of children covered by virtue of Title XXI in the county that serves as the primary location for the eligible professional or eligible hospital.

(2) The SCHIP adjustment will be made by the MPIP system at the time of registration when the eligible professional or eligible hospital selects the county that serves as the primary location for the eligible professional or eligible hospital.

Effective: 01/01/2012
R.C. 119.032 review dates: 01/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.0215
Rule Amplifies: 5111.0215

5101:3-57-02 Medicaid provider incentive program (MPIP): certified electronic health record technology requirements, adopt, implement, or upgrade and meaningful use stage one.

(A) Certified electronic health record (EHR) technology.

(1) In order to qualify for incentive payments, eligible professionals and eligible hospitals are required to select and implement only certified EHR products consistent with the guidelines established by the office of the national coordinator of health information technology (ONC) found at 45 C.F.R. 170 (as in effect on July 28, 2010).

(2) Only MPIP applications that include certification numbers for products certified by the ONC authorized testing and certification bodies (ATCBs) and approved by the ONC will be accepted for processing by MPIP.

(B) Adopt, implement or upgrade (AIU).

(1) Eligible professionals and eligible hospitals applying for year one payment must meet AIU eligibility criteria as defined below:

(a) "Adopt" means acquiring, purchasing or securing access to certified EHR technology; or

(b) "Implement" means installing or commencing utilization of certified EHR technology capable of meeting meaningful use requirements. An eligible professional or eligible hospital must demonstrate actual installation of certified EHR technology prior to receiving an incentive payment, rather than effort to install certified EHR technology; or

(c) "Upgrade" means expanding the available functionality of certified EHR technology capable of meeting meaningful use requirements at the practice site, including staffing, maintenance, and training, or upgrade from existing EHR technology to certified EHR technology per the EHR certification criteria published by the ONC.

(2) Eligible professionals and eligible hospitals will be required to report which certified EHR technology they have adopted, implemented or upgraded to by providing supporting documentation through the MPIP system at the time of registration and attestation, in a manner specified by the Ohio department of job and family services (ODJFS).

(1) MU reporting periods for an eligible professional.

(a) For an eligible professionals second year of payment, the first year for which the eligible professional is demonstrating that he or she is a meaningful user of EHR, the EHR reporting period is a continuous ninety-day period within the calendar year (CY).

(b) For subsequent payment years, the EHR reporting period is the entire CY.

(2) MU reporting periods for an eligible hospital.

(a) For an eligible hospitals second year of payment, the first year for which the hospital is demonstrating that it is a meaningful user of EHR technology, the EHR reporting period is a continuous ninety-day period within the federal fiscal year (FFY).

(b) For subsequent payment years, the EHR reporting period is the entire (FFY).

(D) MU general requirements.

(1) "Meaningful use (MU)" means that certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of care and allows for the submission of clinical quality measures.

(2) Eligible professionals and eligible hospitals must attest to their meaningful use of certified EHR and will be required to provide MU standard specific information indicating that:

(a) The MU standard has been met; or

(b) The particular MU standard does not apply to the provider (and there will be no clinical quality measure); or

(3) Dual eligible hospitals meeting MU criteria for the medicare EHR program will be deemed as meaningful users for MPIP, but will be required to meet additional MPIP program requirements.

(4) To be a meaningful EHR user, at least fifty per cent of an eligible professional's patient encounters during the EHR reporting period during the payment year must occur at a practice/location or practices/locations equipped with certified EHR technology. A practice/location is equipped with certified EHR technology if the certified EHR technology is available at the beginning of the EHR reporting period.

(5) An eligible professional who does not conduct fifty per cent of his or her patient encounters in any one practice/location must meet the fifty per cent threshold through a combination of practices/locations equipped with certified EHR technology.

(6) All MU objectives and measures are limited to actions taken by an eligible professional or eligible hospital at practices/locations equipped with certified EHR technology.

(7) Count of unique patients or actions by an eligible professional or eligible hospital for MU objectives and measures.

(a) If a measure (or associated objective) in paragraphs (E) to (J) of this rule references paragraph (D)(7) of this rule, then the measure may be calculated by reviewing only the actions for patients whose records are maintained using certified EHR technology. A patient's record is maintained using certified EHR technology if sufficient data was entered in the certified EHR technology to allow the record to be saved, and not rejected due to incomplete data.

(b) If the objective and associated measure does not reference paragraph (D)(7) of this rule, then the measure must be calculated by reviewing all patient records, not just those maintained using certified EHR technology.

(c) For purposes of this rule, a "unique patient" means if a patient is seen by an eligible professional more than once during the EHR reporting period, then for purposes of measurement that patient is only counted once in the denominator for the measure.

(E) Eligible professional MU stage one objectives and measures.

(1) An eligible professional must meet the MU criteria established in 42 C.F.R. 495.6 (as in effect on July 28, 2010).

(2) To qualify for an incentive payment an eligible professional must meet a total of twenty MU objectives; fifteen are required core objectives and the remaining five objectives may be chosen from a list of ten menu set objectives.

(3) An eligible professional must report on six total clinical quality measures as defined at 75 Fed. Reg. 44,398 (2010): three required core measures (substituting alternate core measures where necessary) and three additional measures (selected from a set of thirty-eight clinical quality measures).

(4) Exclusion for non-applicable objectives.

(a) An eligible professional may exclude a particular objective, if all of the following requirements are met:

(i) The objective includes an option for the eligible professional to attest that the objective is not applicable.

(ii) The eligible professional meets the criteria in the applicable objective that would permit the attestation.

(iii) The eligible professional attests to meeting the requirements of the exclusion for the non-applicable objective.

(b) An exclusion will reduce (by the number of exclusions applicable) the number of objectives that would otherwise apply. For example, an eligible professional that has an exclusion from one of the menu set objectives in paragraph (G) of this rule shall meet four (and not five) menu set objectives of the eligible professional's choice to meet the definition of a meaningful EHR user.

(F) Stage one core criteria for Eligible professionals. An eligible professional must satisfy the following objectives and associated measures, except those objectives and associated measures for which an eligible professional qualifies for an exclusion under paragraph (E)(4) of this rule:

(1) Eligible professional core objective one:

(a) Objective. Use computerized provider order entry (CPOE) for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines.

(b) Measure. Subject to paragraph (D)(7) of this rule, more than thirty per cent of all unique patients with at least one medication in their medication list seen by the eligible professional have at least one medication order entered using CPOE.

(c) Exclusion in accordance with paragraph (E)(4) of this rule. Any eligible professional who writes fewer than one hundred prescriptions during the EHR reporting period.

(2) Eligible professional core objective two:

(a) Objective. Implement drug-drug and drug-allergy interaction checks.

(b) Measure. The eligible professional has enabled this functionality for the entire EHR reporting period.

(3) Eligible professional core objective three:

(a) Objective. Maintain an up-to-date problem list of current and active diagnoses.

(b) Measure. More than eighty per cent of all unique patients seen by the eligible professional have at least one entry or an indication that no problems are known for the patient recorded as structured data.

(4) Eligible professional core objective four:

(a) Objective. Generate and transmit permissible prescriptions electronically (eRx).

(b) Measure. Subject to paragraph (D)(7) of this rule, more than forty per cent of all permissible prescriptions written by the eligible professional are transmitted electronically using certified EHR technology.

(c) Exclusion in accordance with paragraph (E)(4) of this rule. Any eligible professional who writes fewer than one hundred prescriptions during the EHR reporting period.

(5) Eligible professional core objective five:

(a) Objective. Maintain active medication list.

(b) Measure. More than eighty per cent of all unique patients seen by the eligible professional have at least one entry (or an indication that the patient is not currently prescribed any medication) recorded as structured data.

(6) Eligible professional core objective six:

(a) Objective. Maintain active medication allergy list.

(b) Measure. More than eighty per cent of all unique patients seen by the eligible professional have at least one entry (or an indication that the patient has no known medication allergies) recorded as structured data.

(7) Eligible professional core objective seven:

(a) Objective. Record all of the following demographics:

(i) Preferred language.

(ii) Gender.

(iii) Race.

(iv) Ethnicity.

(v) Date of birth.

(b) Measure. More than fifty per cent of all unique patients seen by the eligible professional have demographics recorded as structured data.

(8) Eligible professional core objective eight:

(a) Objective. Record and chart changes in the following vital signs:

(i) Height.

(ii) Weight.

(iii) Blood pressure.

(iv) Calculate and display body mass index (BMI).

(v) Plot and display growth charts for children ages two through twenty years, including BMI.

(b) Measure. Subject to paragraph (D)(7) of this rule, more than fifty per cent of all unique patients age two and over, seen by the eligible professional, height, weight and blood pressure are recorded as structured data.

(c) Exclusion in accordance with paragraph (E)(4) of this rule. Any eligible professional who either see no patients two years or older, or who believes that all three vital signs of height, weight, and blood pressure of their patients have no relevance to their scope of practice.

(9) Eligible professional core objective nine:

(a) Objective. Record smoking status for patients thirteen years old or older.

(b) Measure. Subject to paragraph (D)(7) of this rule, more than fifty per cent of all unique patients thirteen years old or older seen by the eligible professional have smoking status recorded as structured data.

(c) Exclusion in accordance with paragraph (E)(4) of this rule. Any eligible professional who sees no patients thirteen years or older.

(10) Eligible professional core objective ten:

(a) Objective. Report ambulatory clinical quality measures to ODJFS.

(b) Measure. Subject to paragraph (D)(7) of this rule, successfully report to ODJFS ambulatory clinical quality measures selected by the federal centers for medicare and medicaid services (CMS) in the manner specified by ODJFS.

(11) Eligible professional core objective eleven:

(a) Objective. Implement one clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance with that rule.

(b) Measure. Implement one clinical decision support rule.

(12) Eligible professional core objective twelve:

(a) Objective. Provide patients with an electronic copy of their health information (including diagnostics test results, problem list, medication lists, medication allergies) upon request.

(b) Measure. Subject to paragraph (D)(7) of this rule, more than fifty per cent of all patients who request an electronic copy of their health information are provided it within three business days of the request.

(c) Exclusion in accordance with paragraph (E)(4) of this rule. Any eligible professional that has no requests from patients or their agents for an electronic copy of patient health information during the EHR reporting period.

(13) Eligible professional core objective thirteen:

(a) Objective. Provide clinical summaries for patients for each office visit.

(b) Measure. Subject to paragraph (D)(7) of this rule, clinical summaries provided to patients for more than fifty per cent of all office visits within three business days of the office visit.

(c) Exclusion in accordance with paragraph (E)(4) of this rule. Any eligible professional who has no office visits during the EHR reporting period.

(14) Eligible professional core objective fourteen:

(a) Objective. Capability to exchange key clinical information (for example, problem list, medication list, medication allergies, and diagnostic test results) among providers of care and patient authorized entities electronically.

(b) Measure. Performed at least one test of certified EHR technology's capacity to electronically exchange key clinical information.

(15) Eligible professional core objective fifteen:

(a) Objective. Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities.

(b) Measure. Conduct or review a security risk analysis in accordance with the requirements under 45 C.F.R. 164.308(a)(1) (as in effect on October 1, 2007) and implement security updates as necessary and correct identified security deficiencies as part of its risk management process.

(G) Stage one menu set criteria for eligible professionals. An eligible professional must meet five of the following objectives and associated measures, one of which must be either paragraph (G)(9) or (G)(10) of this rule. If an eligible professional qualifies for an exclusion under paragraph (E)(4) of this rule, the required number of objectives and associated measures in this paragraph is reduced by the eligible professional's number of exclusions.

(1) Eligible professional menu set objective one:

(a) Objective. Implement drug-formulary checks.

(b) Measure. The eligible professional has enabled this functionality and has access to at least one internal or external formulary for the entire EHR reporting period.

(c) Exclusion. In accordance with (E)(4) of this rule. An eligible professional who writes fewer than on hundred prescriptions in the EHR reporting period.

(2) Eligible professional menu set objective two:

(a) Objective. Incorporate clinical lab-test results into EHR as structured data.

(b) Measure. Subject to paragraph (D)(7) of this rule, more than forty per cent of all clinical lab tests results ordered by the eligible professional during the EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data.

(c) Exclusion in accordance with paragraph (E)(4) of this rule. An eligible professional who orders no lab tests whose results are either in a positive/negative or numeric format during the EHR reporting period.

(3) Eligible professional menu set objective three:

(a) Objective. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach.

(b) Measure. Subject to paragraph (D)(7) of this rule, generate at least one report listing patients of the eligible professional with a specific condition.

(4) Eligible professional menu set objective four:

(a) Objective. Send reminders to patients per patient preference for preventive/follow-up care.

(b) Measure. Subject to paragraph (D)(7) of this rule, more than twenty per cent of all patients sixty-five years or older or five years old or younger were sent an appropriate reminder during the EHR reporting period.

(c) Exclusion in accordance with paragraph (E)(4) of this rule. An eligible professional who has no patients sixty-five years old or older or five years old or younger with records maintained using certified EHR technology.

(5) Eligible professional menu set objective five:

(a) Objective. Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, and allergies) within four business days of the information being available to the eligible professional.

(b) Measure. At least ten per cent of all unique patients seen by the eligible professional are provided timely (available to the patient within four business days of being updated in the certified EHR technology) electronic access to their health information subject to the eligible professional's discretion to withhold certain information.

(c) Exclusion in accordance with paragraph (E)(4) of this rule. Any eligible professional that neither orders nor creates any of the information listed at 45 C.F.R. 170.304(g) (as in effect on October 1, 2010) during the EHR reporting period.

(6) Eligible professional menu set objective six:

(a) Objective. Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate.

(b) Measure. More than ten per cent of all unique patients seen by the eligible professional are provided patient-specific education resources.

(7) Eligible professional menu set objective seven:

(a) Objective. The eligible professional who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation.

(b) Measure. Subject to paragraph (D)(7) of this rule, the eligible professional performs medication reconciliation for more than fifty per cent of transitions of care in which the patient is transitioned into the care of the eligible professional.

(c) Exclusion in accordance with paragraph (E)(4) of this rule. An eligible professional who was not the recipient of any transitions of care during the EHR reporting period.

(8) Eligible professional menu set objective eight:

(a) Objective. The eligible professional who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral.

(b) Measure. Subject to paragraph (D)(7) of this rule, the eligible professional who transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than fifty per cent of transitions of care and referrals.

(c) Exclusion in accordance with paragraph (E)(4) of this rule. An eligible professional who neither transfers a patient to another setting nor refers a patient to another provider during the EHR reporting period.

(9) Eligible professional menu set objective nine:

(a) Objective. Capability to submit electronic data to immunization registries or immunization information systems and actual submission according to applicable law and practice.

(b) Measure. Performed at least one test of certified EHR technology's capacity to submit electronic data to immunization registries and follow up submission if the test is successful.

(c) Exclusion in accordance with paragraph (E)(4) of this rule. An eligible professional who administers no immunizations during the EHR reporting period or where no immunization registry has the capacity to receive the information electronically.

(10) Eligible professional menu set objective ten:

(a) Objective. Capability to submit electronic syndromic surveillance data to public health agencies and actual submission according to applicable law and practice.

(b) Measure. Performed at least one test of certified EHR technology's capacity to provide electronic syndromic surveillance data to public health agencies and follow-up submission if the test is successful.

(c) Exclusion in accordance with paragraph (E)(4) of this rule. An eligible professional who does not collect any reportable syndromic information on their patients during the EHR reporting period or does not submit such information to any public health agency that has the capacity to receive the information electronically.

(H) MU stage one objectives and measures for an eligible hospital.

(1) An eligible hospital must meet the MU criteria established in 42 C.F.R. 495.6 (as in effect on July 28, 2010).

(2) To qualify for an incentive payment an eligible hospital must meet a total of nineteen MU objectives; fourteen are required core objectives and the remaining five objectives may be chosen from the list of ten menu set objectives.

(3) An eligible hospital must report on all fifteen clinical quality measures as defined at 75 Fed. Reg. 44,418 (2010).

(4) Exclusions for non-applicable objectives.

(a) An eligible hospital may exclude a particular objective that includes an option for exclusion, if the hospital meets all of the following requirements:

(i) The eligible hospital meets the criteria in the applicable objective that would permit an exclusion.

(ii) The eligible hospital so attests.

(b) An exclusion will reduce (by the number of exclusions received) the number of objectives that would otherwise apply. For example, an eligible hospital that is excluded from one of the menu set objectives in paragraph (J) of this rule must meet four (and not five) objectives of the hospital's choice to meet the definition of a meaningful EHR user.

(I) Stage one core criteria for eligible hospitals. An eligible hospital must meet the following objectives and associated measures except those objectives and associated measures for which an eligible hospital qualifies for an exclusion under paragraph (H)(4) of this rule:

(1) Eligible hospital core objective one:

(a) Objective. Use CPOE for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per State, local, and professional guidelines.

(b) Measure. Subject to paragraph (D)(7) of this rule, more than thirty per cent of all unique patients with at least one medication in their medication list admitted to the eligible hospitals inpatient or emergency department (place of service (place of service (POS) 21 or 23) have at least one medication order entered using CPOE.

(2) Eligible hospital core objective two:

(a) Objective. Implement drug-drug and drug-allergy interaction checks.

(b) Measure. The eligible hospital has enabled this functionality for the entire EHR reporting period.

(3) Eligible hospital core objective three:

(a) Objective. Maintain an up-to-date problem list of current and active diagnoses.

(b) Measure. More than eighty per cent of all unique patients admitted to the eligible hospitals inpatient or emergency department (POS 21 or 23) have at least one entry or an indication that no problems are known for the patient recorded as structured data.

(4) Eligible hospital core objective four:

(a) Objective. Maintain active medication list.

(b) Measure. More than eighty per cent of all unique patients admitted to the eligible hospitals inpatient or emergency department (POS 21 or 23) have at least one entry (or an indication that the patient is not currently prescribed any medication) recorded as structured data.

(5) Eligible hospital core objective five:

(a) Objective. Maintain active medication allergy list.

(b) Measure. More than eighty per cent of all unique patients admitted to the eligible hospitals inpatient or emergency department (POS 21 or 23) have at least one entry (or an indication that the patient has no known medication allergies) recorded as structured data.

(6) Eligible hospital core objective six:

(a) Objective. Record all of the following demographics;

(i) Preferred language.

(ii) Gender.

(iii) Race.

(iv) Ethnicity.

(v) Date of birth.

(vi) Date and preliminary cause of death in the event of mortality in the eligible hospital.

(b) Measure. More than fifty per cent of all unique patients admitted to the eligible hospitals inpatient or emergency department (POS 21 or 23) have demographics recorded as structured data.

(7) Eligible hospital core objective seven:

(a) Objective. Record and chart changes in the following vital signs:

(i) Height.

(ii) Weight.

(iii) Blood pressure.

(iv) Calculate and display body mass index (BMI).

(v) Plot and display growth charts for children ages two through twenty years, including BMI.

(b) Measure. Subject to paragraph (D)(7) of this rule, for more than fifty per cent of all unique patients age two and over admitted to the eligible hospitals inpatient or emergency department (POS 21 or 23), height, weight, and blood pressure are recorded as structured data.

(8) Eligible hospital core objective eight:

(a) Objective. Record smoking for patients thirteen years old or older.

(b) Measure. Subject to paragraph (D)(7) of this rule, more than fifty per cent of all unique patients thirteen years old or older or admitted to the eligible hospitals inpatient or emergency department (POS 21 or 23) have smoking status recorded as structured data.

(c) Exclusion in accordance with paragraph (H)(4) of this rule. Any eligible hospital that admits no patients thirteen years or older to their inpatient or emergency department (POS 21 or 23).

(9) Eligible hospital core objective nine:

(a) Objective. Report hospital clinical quality measures to ODJFS.

(b) Measure. Subject to paragraph (D)(7) of this rule, successfully report to ODJFS hospital clinical quality measures selected by CMS in the manner specified by ODJFS.

(10) Eligible hospital core objective ten:

(a) Objective. Implement one clinical decision support rule related to a high priority hospital condition along with the ability to track compliance with that rule.

(b) Measure. Implement one clinical decision support rule.

(11) Eligible hospital core objective eleven:

(a) Objective. Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies, discharge summary, procedures) upon request.

(b) Measure. Subject to paragraph (D)(7) of this rule, more than fifty per cent of all patients of the inpatient or emergency departments of the eligible hospital (POS 21 or 23) who request an electronic copy of their health information are provided it within three business days of the request.

(c) Exclusion in accordance with paragraph (H)(4) of this rule. Any eligible hospital that has no requests from patients or their agents for an electronic copy of patient health information during the EHR reporting period.

(12) Eligible hospital core objective twelve:

(a) Objective. Provide patients with an electronic copy of their discharge instructions at time of discharge, upon request.

(b) Measure. Subject to paragraph (D)(7) of this rule, more than fifty per cent of all patients who are discharged from a eligible hospitals inpatient or emergency department (POS 21 or 23) and who request an electronic copy of their discharge instructions are provided it.

(c) Exclusion in accordance with paragraph (H)(4) of this rule. Any eligible hospital that has no requests from patients or their agents for an electronic copy of the discharge instructions during the EHR reporting period.

(13) Eligible hospital core objective thirteen:

(b) Measure. Performed at least one test of certified EHR technology's capacity to electronically exchange key clinical information.

(14) Eligible hospital core objective fourteen:

(a) Objective. Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities.

(b) Measure. Conduct or review a security risk analysis in accordance with the requirements under 45 C.F.R. 164.308(a)(1) (as in effect on October 7, 2007) and implement security updates as necessary and correct identified security deficiencies as part of its risk management process.

(J) Stage one menu set criteria for eligible hospitals. Eligible hospitals must meet five of the following objectives and associated measures, one of which must be either paragraph (J)(8), (J)(9), or (J)(10) of this rule. If an eligible hospital qualifies for an exclusion under paragraph (H)(4) of this rule, the required number objectives and associated measures in this paragraph is reduced by the eligible hospitals number of exclusions.

(1) Eligible hospital menu set objective one:

(a) Objective. Implement drug-formulary checks.

(b) Measure. The eligible hospital has enabled this functionality and has access to at least one internal or external formulary for the entire EHR reporting period.

(2) Eligible hospital menu set objective two:

(a) Objective. Record advance directives for patient sixty-five years old or older.

(b) Measure. Subject to paragraph (D)(7) of this rule, more than fifty per cent of all unique patients sixty-five years old or older admitted to the eligible hospitals inpatient (POS 21) have an indication of an advance directive status recorded as structured data.

(c) Exclusion in accordance with paragraph (H)(4) of this rule. An eligible hospital that admits no patients age sixty-five years old or older during the EHR reporting period.

(3) Eligible hospital menu set objective three:

(a) Objective. Incorporate clinical lab-test results into EHR as structured data.

(b) Measure. Subject to paragraph (D)(7) of this rule, more than forty per cent of all clinical lab test results ordered by an authorized provider of the eligible hospital for patients admitted to its inpatient or emergency department (POS 21 and 23) during the EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data.

(4) Eligible hospital menu set objective four:

(a) Objective. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach.

(b) Measure. Subject to paragraph (D)(7) of this rule, generate at least one report listing patients of the eligible hospital with a specific condition.

(5) Eligible hospital menu set objective five:

(a) Objective. Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate.

(b) Measure. More than ten per cent of all unique patients admitted to the eligible hospitals inpatient or emergency department (POS 21 or 23) are provided patient-specific education resources.

(6) Eligible hospital menu set objective six:

(a) Objective. The eligible hospital who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation.

(b) Measure. Subject to paragraph (D)(7) of this rule, the eligible hospital performs medication reconciliation for more than fifty per cent of transitions of care in which the patient is admitted to the eligible hospitals inpatient or emergency department (POS 21 or 23).

(7) Eligible hospital menu set objective seven:

(a) Objective. The eligible hospital that transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary care record for each transition of care or referral.

(b) Measure. Subject to paragraph (D)(7) of this rule, the eligible hospital that transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than fifty per cent of transitions of care and referrals.

(8) Eligible hospital menu set objective eight:

(a) Objective. Capability to submit electronic data to immunization registries or immunization information systems and actual submission according to applicable law and practice.

(b) Measure. Performed at least one test of certified EHR technology's capacity to submit electronic data to immunization registries and follow up submission if the test is successful.

(c) Exclusion in accordance with paragraph (H)(4) of this rule. An eligible hospital that administers no immunizations during the EHR reporting period or where no immunization registry has the capacity to receive the information electronically.

(9) Eligible hospital menu set objective nine:

(a) Objective. Capability to submit electronic data on reportable (as required by state or local law) lab results to public health agencies and actual submission according to applicable law and practice.

(b) Measure. Performed at least one test of certified EHR technology's capacity to provide electronic submission of reportable lab results to public health agencies and follow-up submission if the test is successful.

(c) Exclusion in accordance with paragraph (H)(4) of this rule. No public health agency to which the eligible hospital submits such information has the capacity to receive the information electronically.

(10) Eligible hospital menu set objective ten:

(a) Objective. Capability to submit electronic syndromic surveillance data to public health agencies and actual submission according to applicable law and practice.

(c) Exclusion in accordance with paragraph (H)(4) of this rule. No public health agency to which the eligible hospital submits information has the capacity to receive the information electronically.

(K) Demonstration of MU objectives and measures.

(1) An eligible professional and eligible hospital must demonstrate that MU objectives and measures are met, in accordance with 42 C.F.R. 495.8 (as in effect on July 28, 2010).

(a) Eligible professionals and eligible hospitals must attest, through a secure mechanism, in a manner specified by ODJFS, that during the EHR reporting period, the eligible professional and eligible hospital:

(i) Used certified EHR technology, and specify the technology used;

(ii) Satisfied the required objectives and associated measures under paragraphs (E) to (J) of this rule; and

(iii) Specified the EHR reporting period and provided the result of each applicable measure for all patients seen during the EHR reporting period for which a selected measure is applicable.

(L) Demonstration of MU is subject to review by both ODJFS and CMS.

Effective: 01/01/2012
R.C. 119.032 review dates: 01/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.0215
Rule Amplifies: 5111.0215

5101:3-57-03 Medicaid provider incentive program (MPIP): incentive payments (calculation, duration, amount and limit).

(A) Medicaid provider incentive program (MPIP) incentive payments.

(1) MPIP incentive payments will be calculated in accordance with 42 C.F.R. 495.310 (as in effect on July 28, 2010).

(2) An eligible professional or eligible hospital will be eligible to receive the federally specified incentive payment amount, regardless of the purchase or implementation costs of their electronic health record (EHR) system as long as the eligible professional or eligible hospital meets all MPIP program eligibility requirements as specified in Chapter 5101:3-57 of the Administrative Code.

(3) In no case may any medicaid eligible professional or eligible hospital receive an incentive payment after payment year 2021.

(4) "Payment year" means:

(a) For an eligible professional, a calendar year (CY) beginning with CY 2011; and

(b) For an eligible hospital, a federal fiscal year (FFY) beginning with FFY 2011.

(B) Eligible professional incentive payments.

(1) First payment year requirements.

(a) The first payment year for an eligible professional is the first CY for which the eligible professional receives an incentive payment.

(b) In the first payment year, to receive an incentive payment, the medicaid eligible professional must demonstrate the following:

(i) That during the payment year he or she met all eligible professional eligibility requirements defined in rule 5101:3-57-01 of the Administrative Code; and

(ii) That he or she adopted, implemented or upgraded to certified EHR technology pursuant to paragraph (B) of rule 5101:3-57-02 of the Administrative Code.

(d) Eligible professionals may not begin receiving payments any later than CY 2016.

(2) Requirements in subsequent payment years.

(a) The second, third, fourth, fifth, or sixth payment year for an eligible professional is the second, third, fourth, fifth, or sixth CY for which the eligible professional receives an incentive payment regardless of whether the year immediately follows the prior payment year.

(b) In the second, third, fourth, fifth and sixth payment years, to receive incentive payment, the medicaid eligible professional must demonstrate the following:

(i) That he or she has met all eligible professional eligibility requirements defined in rule 5101:3-57-01 of the Administrative Code; and

(ii) That during the EHR reporting period for the applicable payment year, he or she is a meaningful EHR user of certified EHR technology as defined in rule 5101:3-57-02 of the Administrative Code.

(d) Eligible professionals may receive payments in non-consecutive years.

(3) An eligible professional shall not participate for more than a total of six payment years, and in no case will the maximum incentive payments over a six-year period exceed sixty-three thousand seven hundred fifty dollars.

(4) The following limitations apply:

(a) An eligible professional who is a pediatrician, as defined in paragraph (C)(4)(b) of rule 5101:3-57-01 of the Administrative Code, with a patient volume of less than thirty per cent, but who meets the patient volume requirement of at least twenty per cent, is limited to the following:

(i) The maximum payment in the first payment year is fourteen thousand one hundred sixty-seven dollars.

(ii) The maximum payment in subsequent years is five thousand six hundred sixty-seven dollars.

(iii) The maximum amount for a pediatrician under this limitation shall not exceed forty-two thousand five hundred dollars.

(iv) Pediatricians meeting the thirty per cent patient volume threshold in a payment year may be eligible to receive the maximum incentive payment amount, for that payment year as defined in paragraphs (B)(1) to (B)(3) of this rule.

(5) An eligible professional who switches to MPIP from the medicare EHR incentive payment program is placed in the payment year that the eligible professional would have been in had the eligible professional begun in, and remained in, the medicare EHR incentive payment program in accordance with 42 C.F.R. 495.10 (as in effect on July 28, 2010).

(6) Reassignment of payment.

(a) Assignment of the incentive payment must be consistent with federal and state medicaid laws, rules, and regulations, (including without limitation, fraud, waste, and abuse laws rules and regulations).

(b) Eligible professionals may reassign incentive payments to an employer or entity with which the eligible professional has a valid contractual arrangement allowing the employer or entity to bill for and receive payment for the eligible professional's covered professional services. The employer or entity for which payment is reassigned must be an Ohio medicaid provider with an active Ohio medicaid provider agreement.

(c) An eligible professional may not reassign an incentive payment to more than one employer or entity. In cases where eligible professionals are associated with more than one practice, the eligible professional must select one tax identification number to receive any applicable EHR incentive payment.

(1) First payment year requirements.

(a) The first payment year for an eligible hospital is the first FFY for which the eligible hospital receives an incentive payment.

(b) In the first payment year, to receive an incentive payment, the medicaid eligible hospital must demonstrate the following:

(i) That during the payment year it met all eligible hospital eligibility requirements defined in rule 5101:3-57-01 of the Administrative Code; and

(ii) That it has adopted, implemented or upgraded to certified EHR technology pursuant to paragraph (B) of rule 5101:3-57-02 of the Administrative Code.

(2) Subsequent payment year's requirements.

(a) The second, third, fourth, fifth, or sixth payment year for an eligible hospital is the second, third, fourth, fifth, or sixth FFY for which the hospital receives an incentive payment.

(b) In the second, third, fourth, fifth and sixth payment years, to receive incentive payment, the medicaid eligible hospital must demonstrate the following:

(i) That it has met all eligible hospital eligibility requirements defined in rule 5101:3-57-01 of the Administrative Code; and

(ii) That during the EHR reporting period for the applicable payment year, it is a meaningful EHR user of certified EHR technology as defined in rule 5101:3-57-02 of the Administrative Code.

(3) An incentive payment to an eligible hospital is subject to the following conditions:

(a) No eligible hospital may begin receiving incentive payments for any year after FFY 2016.

(b) Prior to FFY 2016, payments may be made to an eligible hospital on a non-consecutive, annual basis for a FFY.

(c) After FFY 2016, a hospital may not receive an incentive payment unless it received an incentive payment in the prior FFY.

(d) A multi-site hospital with one federal centers for medicare and medicaid services (CMS) certification number is considered one hospital for purposes of calculating payment.

(4) Eligible hospital incentive payments will be calculated in accordance with 42 C.F.R. 495.310 (as in effect on July 28, 2010).

(5) All data used to calculate the hospital EHR incentive payment amount must be provided through the MPIP system at the time of the eligible hospital's application and attestation, in a manner specified by the Ohio department of job and family services (ODJFS).

(6) All eligible hospital calculations of the aggregate EHR hospital incentive payment made at the time of MPIP application are subject to review and may be adjusted based on review findings.

(7) An eligible hospital may be paid up to one hundred per cent of the calculated aggregate EHR incentive amount over a four-year period, if it meets all MPIP program eligibility requirements: forty per cent in year one; thirty per cent in year two; twenty per cent in year three; and ten per cent in year four.

(8) An eligible hospital may not alter or modify data elements used to calculate the hospital EHR incentive payment after MPIP has processed an eligible hospitals application for payment and payment has been disbursed for the payment year.

(D) Issuance of payments.

(1) MPIP incentive payment will be issued and disbursed in compliance with 42 C.F.R. 495.312 (as in effect on July 28, 2010).

(2) Payments will be made to the taxpayer identification number selected at the time of registration.

(E) Offsets, adjustments and recoupment of payment.

(1) MPIP payments are subject to offsets, adjustments and recoupments. These and/or other collection methods will be applied to the medicaid EHR incentive payments to reimburse or pay for medicaid overpayments, fines, penalties, or other debts owed by the provider or its assignee(s) to the medicaid state agency, Ohio county or local governments, the department of health and human services, or any other federal agency.

(2) ODJFS will identify and recoup overpayments made under the incentive program that result from incorrect or fraudulent attestations, quality measures, cost data, patient data, or any other submission required to establish eligibility or qualify for a payment.

(3) Eligible professionals and eligible hospitals must report any suspected overpayments of an incentive payment to ODJFS within sixty days of its discovery.

Effective: 09/10/2012
R.C. 119.032 review dates: 01/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.0215
Rule Amplifies: 5111.0215
Prior Effective Dates: 1/1/2012

5101:3-57-04 Medicaid provider incentive program (MPIP): program integrity and provider appeals.

(A) Program integrity.

(1) MPIP legal notice.

(a) All eligible professionals and eligible hospitals submitting an application to receive an MPIP payment are required to sign the MPIP legal notice before confirming and submitting their application.

(b) All program applicants are bound by the requirements of the MPIP legal notice.

(2) Eligible professional and eligible hospital MPIP applications and attestations are subject to verification by the Ohio department of job and family services (ODJFS).

(3) For any given payment year an eligible professional and eligible hospital must register for MPIP by the end of the calendar year (CY) for an eligible professional and federal fiscal year (FFY) for an eligible hospital.

(4) An eligible professional and eligible hospital will have sixty days after the end of the CY for an eligible professional and FFY for and eligible hospital to complete attestation via the MPIP system for a given payment year.

(5) Post payment audits and record retention.

(a) An eligible professional's and eligible hospital's MPIP application and attestation are subject to a post payment audit.

(b) ODJFS or its designee, the state auditor's office, the state attorney general's office and the federal centers for medicare and medicaid services (CMS) may conduct reviews and audits of MPIP applications for the purpose of determining compliance with the requirements of this chapter as well as with applicable state and federal requirements.

(c) Audits and reviews may be conducted on-site as determined necessary based on periodic analysis of medical, financial, and other information.

(d) Records stored electronically must be produced at the eligible professional's or eligible hospital's expense, upon request, in the format specified by ODJFS.

(e) All records must be maintained for a minimum of seven years following the last day of the CY for eligible professionals or FFY for eligible hospitals in which payment related to the attestation has been received, or in the event that the eligible professional or eligible hospital has been notified that state or federal authorities have commenced an audit or investigation of their MPIP application, until such time as the matter under audit, appeal or investigation has been resolved.

(f) An eligible professional and eligible hospital must comply with all audit recoveries.

(6) Fraud, waste, and abuse.

(a) Suspicion or detection of fraud and abuse by ODJFS will be referred to the medicaid fraud control unit (MFCU) in the office of the attorney general (AG). Referrals to the MFCU will be investigated for prosecutorial merit.

(b) Substantiated cases of fraud and abuse will be prosecuted according to federal and state regulations.

(B) Provider appeals.

(1) An eligible professional or eligible hospital may appeal the following issues related to MPIP, by first requesting an informal review:

(a) Incentive payment amounts.

(b) Provider eligibility determinations (i.e. patient volume, hospital-based).

(2) Appeals filed after the deadlines specified in paragraphs (B)(3)(a) and (B)(4)(a) of this rule, will be dismissed without the ability to refile. If the deadline falls on a saturday, sunday, state or federal holiday, the period for requesting an appeal will be extended to the next business day.

(3) Informal review.

(a) If the MPIP system has made a preliminary determination that may be adverse regarding the incentive payment application of an eligible professional or eligible hospital, the eligible professional or eligible hospital may request an informal review of the preliminary determination via the MPIP system, within fifteen calendar days of notification of an adverse preliminary determination.

(b) A request for informal review shall be made via the MPIP system and may include supporting documentation to support the request.

(c) An eligible professional or eligible hospital will be notified of the informal review decision via email and will be advised to log into the MPIP system to see the details of the review decision.

(d) An eligible professional or eligible hospital may withdraw the request for an informal review via the MPIP system, without reason, at any time, after the initial filing and before an informal review decision is issued.

(4) Request for reconsideration.

(a) If the informal review upholds the preliminary adverse determination and the eligible professional or eligible hospital does not agree with the informal review decision, the eligible professional or eligible hospital may submit a written request for reconsideration no later than fifteen calendar days after the date of notification of determination via the MPIP system.

(b) The request for reconsideration shall be initiated via the MPIP system and must include a written and signed letter from the eligible professional or eligible hospital containing the following information:

(i) Clear identification of the affected eligible professional or eligible hospital;

(ii) The proposed action being contested;

(iii) The basis for requesting reconsideration; and

(iv) Supporting documentation being submitted.

(c) The written request for reconsideration must be signed, dated, include any supporting documentation and must be uploaded via the MPIP system.

(d) An eligible professional or eligible hospital will be notified in writing, by certified mail, of the reconsideration decision.

(5) In accordance with Chapter 2505. of the Revised Code, an eligible professional or eligible hospital may appeal the reconsideration decision by filing a notice of appeal with the court of common pleas of Franklin county. The notice shall identify the decision being appealed and the specific grounds for the appeal. The notice of appeal shall be filed not later than fifteen days after the department mails its notice of the reconsideration decision. A copy of the notice of appeal shall be filed with the department not later than three days after the notice is filed with the court.

Effective: 09/10/2012
R.C. 119.032 review dates: 01/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.0215
Rule Amplifies: 5111.0215
Prior Effective Dates: 1/1/2012