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  • Archived Website Content
    • Adopt/Implement/Upgrade (AIU) Attestation - (Web)
    • Prepayment Review Scenarios Presentation - (PDF)
    • EP AIU Attestation 2016 - (PDF)
    • EP AIU Presentation - (PDF)
    • EP 2015 MU1 Presentation - (PDF)
    • EP 2015 MU2 Presentation - (PDF)
    • Attestation Deadline Extension (ADE) Form - (XLS) - (Web)
    • Greenway EHR Identification Form - (XLSX) - (Web)
    • Group EPs Pre-Validation - (XLSX)
    • Individual EPs Pre-Validation - (XLSX)
    • Numerator Request Form - (XLSX)
    • NY Medicaid EHR Incentive Program MPV Workbook - (XLS)
  • Submitting Documentation Quick Reference Guide - (PDF)
  • Archived Public Health Reporting FAQs - (Web)
  • Archived Population Health Registry - (Web)
  • Archived Website Content - (Web)

Tutorial 5: Submitting Documentation - (YouTube)

This tutorial serves as a guide for Eligible Hospitals and Eligible Professionals participating in the New York Medicaid EHR Incentive Program, who are preparing for an audit of his or her adopt, implement, or upgrade (AIU) or Meaningful Use (MU) activity. This tutorial will discuss submitting documentation to your auditor and navigating OMIG's HIPAA compliant drop box, Hightail.

EP30 I signed and sent in my paper attestation, what can I expect now?

Published: 04/26/2012
Updated: 04/26/2016

The below steps outline the attestation review and incentive payment check disbursement process:

Step 1: Attestation e-filed by the Department of Health (DOH)

Once the attestation is received by NY Medicaid, the attestation will be e-filed by NY Medicaid for data retention and passed on to the NY Medicaid EHR Incentive Program Support Service for review. Allow 9-10 business days from the day sent by mail to confirm if NY Medicaid has received the Eligible Professional´s (EP´s) paper attestation.

Step 2: NY Medicaid EHR Incentive Program Attestation Review

The NY Medicaid EHR Incentive Program review timeline varies as it is dependent on volume of attestations and validation failures. Attestations are processed in the order received and every effort is made to expedite review so payment can be made.

  1. Approval Process
    If the attestation meets all requirements and passes the validation criteria, the EP´s attestation will be approved and sent on to the Center for Medicare and Medicaid Services (CMS) for final approval.
  2. Rejection Process
    If the attestation does not meet all requirements or does not pass the validation criteria, the EP´s attestation will be rejected for re-attestation. The EP has the opportunity to resubmit the attestation using corrected data or provide supporting documentation to remediate validation concerns.
  3. Denial Process
    If the attestation does not meet all requirements or does not pass the validation criteria, the EP´s attestation will be rejected for re-attestation. The EP has the opportunity to resubmit the attestation using corrected data or provide supporting documentation to remediate validation concerns.

Step 3: CMS Attestation Review

After passing the NY Medicaid EHR Incentive Program review, the approved attestation is sent to CMS for final review. NY Medicaid is notified by CMS of final approval or denial within 1 week from the initial CMS submission date. The NY Medicaid EHR Incentive Program Support Service will alert the EP via a notification email if the attestation has been officially approved or denied for incentive payment.

Step 4: Incentive Payment Disbursement

The EP´s incentive payment will be disbursed as a lump sum payment in the weekly Medicaid payment run following CMS final approval. The incentive payment will released using existing channels and processes for paying Medicaid fee-for-service providers.

Track your attestation contact the NY Medicaid EHR Incentive Program Support by emailing HIT@health.ny.gov.

EP33 It´s been more than 90 days since I submitted my attestation. What is holding up my application?

Published: 01/14/2014
Updated: 05/11/2015

Eligible Professionals (EP) are advised to please check the email address registered with Center for Medicare and Medicaid Services (CMS) for mail from the EHR Incentive Program. If there are any questions, please contact the NY Medicaid EHR Incentive Program Support at 1-877-646-5410, Option 2 or HIT@health.ny.gov.

Please note that NY Medicaid EHR Incentive Program Support cannot review data until 90 days have passed from the end date of the 90-day Medicaid Patient Volume Reporting Period. This period is required to allow Medicaid claims to be processed and finalized.

EP37 I am a Physician Assistant (PA) practicing in an FQHC/RHC that is led by a PA. I want to attest to the 30% Medicaid patient volume but MEIPASS only allows me to attest under the needy patient volume.

Published: 06/13/2012

Updated: 06/28/2019

Although Physician Assistants (PAs) are allowed to qualify for the NY Medicaid EHR Incentive Program by demonstrating either a 30% Medicaid patient volume or (if they practice predominately in the FQHC/RHC) a 30% needy patient volume, MEIPASS does not currently allow PAs to select the standard patient volume or Patient Panel methods. In order to correctly select "Yes" to the "Practice as a Physician Assistant" question in MEIPASS, it is necessary to also select "Practice Predominately at an FQHC/RHC" and demonstrate that at least 50% of encounters over a 6-month period in the prior calendar year took place at the FQHC/RHC. This is a known issue, and the NYS Department of Health (DOH) is in the process of updating MEIPASS to allow PAs to qualify using Medicaid patient volume.

In the interim, the DOH has approved the following workaround to allow PAs who practice predominately in an FQHC/RHC to attest using their Medicaid patient volume:

  1. Answer "Yes" to "In the previous year, for any consecutive 6-month period, were 50% or more of your patient encounters at an FQHC or RHC, and do you intend to use needy patient volume to qualify?" and fill out the required patient volume information. If the PA does not practice predominately in an FQHC or RHC he or she may fill the data fields (Patient Encounters at FQHC or RHC, Total Patient Encounters) with all 9´s.
  2. Continue to complete the eligibility information on the following screen. Under "Eligible Patient Volume", the question "Practices Predominately in an FQHC/RHC" should be answered "Yes".
  3.  
    1. If you wish to use the standard method of calculating Medicaid patient volume, complete the "FQHC/RHC Encounters" fields as indicated in Table 1 below.
    2. If you wish to use the Patient Panel method of calculating Medicaid patient volume, answer "Yes" to "Include FQHC/RHC MCO Patient Volume" and complete the "Needy Patient Panel Volume" fields as indicated in Table 2 below.
  4. Complete and submit the MEIPASS attestation.
    NOTE: Effective payment year 2017, EP attestations are submitted completely online via MEIPASS. The MEIPASS attestation document does not need to be mailed to the NY Medicaid EHR Incentive Program. Steps 5 through 7 are not required for payment years 2017 and beyond.
  5. After printing the attestation document, make the following changes directly on the attestation document before sending it to the DOH:
  6.  
    1. Locate the blank fields for the Medicaid patient volume method you wish to use ("Standard Patient Volume Calculation" or "Patient Panel Volume Calculation"). Clearly write the correct patient volume numbers corresponding to the desired method directly in the blank fields using blue or black ink. Initial next to each field.
    2. Locate the section for the needy patient volume method you selected in MEIPASS ("Needy Patient Volume Calculation" or "Needy Patient Panel Volume Calculation"). Using blue or black ink, cross out the label of the patient volume method and write "Using Medicaid patient volume for Physician Assistant" and initial immediately below the label.
  7. Send the attestation document to DOH as directed on the first page. We recommend keeping a photocopy of the modified attestation document for your records.
Table 1: STANDARD METHOD
Field Name Directions
Total Medicaid Encounters Enter the number of Medicaid encounters during the 90–day patient volume reporting period.
Total CHIP Encounters Enter 0.
Total Charity Care Encounters Enter 0.
Total Sliding Fee Scale Encounters Enter 0.
Total Encounters Enter the total number of encounters during the 90–day patient volume reporting period.

Table 2: PATIENT PANEL METHOD
Field Name Directions
Total Medicaid Patients Enter the number of Medicaid patients current on your patient panel during the 90–day patient volume reporting period with whom you had at least one encounter during the calendar year prior to the reporting period.
Total CHIP Patients Enter 0.
Total Charity Care Patients Enter 0.
Total Sliding Fee Scale Patients Enter 0.
Total Unduplicated Medicaid Encounters Enter the number of Medicaid encounters during the 90–day patient volume reporting period for patients not on the patient panel.
Total Unduplicated CHIP Encounters Enter 0.
Total Unduplicated Charity Care Encounters Enter 0.
Total Unduplicated Sliding Fee Scale Encounters Enter 0.
Total Patients Enter the number of patients current on your patient panel during the 90–day patient volume reporting period with whom you had at least one encounter during the calendar year prior to the reporting period.
Total Unduplicated Encounters Enter the number of encounters during the 90–day patient volume reporting period for patients not on the patient panel.

EP52 What should a provider do if he/she realizes that they´ve falsely attested?

Published: 05/14/2014
Updated: 03/16/2015

If a provider wishes to self-report that they have falsely attested prior to receiving an Audit Notification Letter, they should contact the NY Medicaid EHR Incentive Program Support Team at 1-877-646-5410 (option #2), or email HIT@health.ny.gov for assistance. If based on an audit, a provider is found to not be eligible for an EHR incentive payment, the payment will be recouped and providers will be ineligible to re-attest for that payment year.

EP53 How should HIPAA documentation be sent to OMIG?

Published: 05/14/2014

HIPAA-sensitive information can be sent in any secure method of the provider´s choosing such as encrypted email or certified mail. We highly recommend using OMIG´s secure HIPAA-compliant drop box known as Hightail. This drop box will allow supporting documentation to be securely uploaded to the auditor.

EP71 I made a mistake on my attestation and should not have received the incentive payment. How do I return the incentive payment? Will I be ineligible to participate in subsequent years of the program?

Published: 04/09/2015

For providers that need to self-report that they were unable to meet the program requirements and had received the incentive payment in error, please contact NY Medicaid EHR Incentive Program Support at hit@health.ny.gov.

Self-reporting is by payment year. Although a provider may return the incentive payment for a particular payment year, that does not forfeit the provider's eligibility to participate in subsequent years. If the provider meets program requirements for subsequent years, then the provider may continue participating in the NY Medicaid EHR Incentive Program.

Please note that inquiries related to recoupments of incentive payments due to post-payment audits should be directed to the Office of the Medicaid Inspector General at hitech@omig.ny.gov.

EP88 How can an eligible professional attest to an EHR reporting period greater than 90 days for payment year 2015 or 2016?

Published: 04/28/2017

NY Medicaid is aware that MEIPASS automatically populates a minimum EHR reporting period. To attest to an EHR reporting period greater than 90 days, please follow this workaround procedure for payment years 2015 and 2016:

In MEIPASS:
  1. Enter the provider´s EHR reporting start date. A 90-day period end date will automatically populate.
  2. Complete the attestation requirements in MEIPASS.
  3. Print the MEIPASS attestation document.
  4. Using blue or black ink, cross out the EHR reporting end date.
  5. Clearly write the correct end date (MM/DD/YYYY) for the provider´s EHR reporting period.

    Important: The end date must be within the payment year.
  6. Mark your initials next to the corrected end date.
In the Meaningful Use (MU) Workbook:
  1. Enter the provider´s EHR reporting start and end dates.
  2. Complete the attestation requirements in the MU workbook.
  3. Email the completed MU workbook to attestation@health.ny.gov and include "EHR Reporting Workaround" in the subject line of the message.
  4. Print the completed MU workbook.
Mail the completed MEIPASS attestation document and MU workbook to:
NY Medicaid EHR Incentive Program Administrative Support Service
PO Box 809
Rensselaer, NY 12144-0809

Recommendation: Providers should retain copies of this FAQ as well as their attestation documents.

EP91 What should an Eligible Professional (EP) attest to if the Clinical Quality Measure (CQM) version in MEIPASS differs from the CQM version displayed in their Certified EHR Technology (CEHRT) for a particular Payment Year (PY)?

Published: 7/16/2018
Updated: 08/31/2020

NY Medicaid is aware that MEIPASS may present a CQM which differs from the CQM version in the Eligible Professional´s (EP´s) Certified EHR Technology (CEHRT) for a particular Payment Year (PY). The version differences experienced by an EP may be presented, but are not limited to the following:

  • An additional denominator exclusion(s) for a particular CQM.
  • A language variation for a numerator, denominator and/or denominator exclusion(s).

If the EP wishes to attest to a CQM impacted by one of these differences, please utilize the below attestation workaround procedure:

  1. Enter 999999999 in the CQM field that does not align with EP´s CEHRT
    1. Denoting 999999999 will alert NY Medicaid that you are using this approved workaround.
    2. Do not enter a zero in place of this workaround. Please refer to FAQ EPH33 for additional guidance regarding entering a zero in a CQM.

Additional Resources:

EP95 How should an Eligible Professional (EP) attest if their EHR Vendor has not made the 2021 CQM specifications available?

Published: 06/28/2021

If an EP´s ability to attest is impacted by their EHR vendor´s delivery of their 2021 CQMs, they should utilize the below attestation workaround procedure:

  1. Utilize their 2020 CQM report with 999999999 in the selected CQM field
    1. Denoting 999999999 will alert NY Medicaid that you are using this approved workaround.
    2. Do not enter a zero in place of this workaround. Please refer to FAQ EPH33 for additional guidance regarding entering a zero in a CQM.

    2. Additional Resources:

    M04 How does a provider add or remove an EHR Certification Number in MEIPASS?

    Published: 04/30/2014

    Removed: 07/01/2016

    Reposted: 02/03/2017

    A provider´s EHR Certification Number can be submitted at the CMS Registration and Attestation System or within MEIPASS. Use the step by step process below to determine how to add or remove an EHR Certification Number within a provider´s attestation record in MEIPASS.

    STEP 1: Locate and verify if an EHR Certification Number was entered

    • Log into MEIPASS
    • Enter the CMS Registration ID and click "Submit"
    • The Registration Screen will display, Click "Begin Attestation" or "Continue Attestation"*
    • The Eligibility Screen will display (see image in Fig A. below)
    • Proceed to Step 2: Determine Remediation Path

    *If the "Attest" button does not display, then the provider´s attestation is currently locked for review. Please contact 1-877-646-5410, Option 2 for further instructions on if the provider should or shouldn´t change the EHR Certification Number.

    log into meipass

    Fig. A EHR Certification Number Section - Eligibility screen will vary slightly based on remediation path.

    STEP 2: Determine the remediation path

    Path 1: EHR Certification Number that the provider can remove in MEIPASS.
    • Log into MEIPASS
    • Enter the CMS Registration ID and click "Submit"
    • Click "Attest" and MEIPASS will navigate you to the "Eligibility Screen"
    • Locate the invalid EHR Certification Number and click "Remove"
    • Input the valid EHR Certification Number and click "Add"
    • Complete the rest of the Eligibility Section
    • Click "Save" and continue on with the attestation process
    Path 2: EHR Certification Number that the provider cannot remove in MEIPASS.
    • Log into the CMS Registration and Attestation System. (EP Registration Guide)
    • Remove the EHR Certification Number for the provider´s registration record
    • Submit the updated registration to NY Medicaid
    • Wait 1 business day for the change to occur in MEIPASS
    • Log into MEIPASS
    • Enter the CMS Registration ID and click "Submit"
    • Click "Attest" and MEIPASS will navigate you to the "Eligibility Screen"
    • Input the valid EHR Certification Number and click "Add"
    • Complete the rest of the Eligibility Section
    • Click "Save" and continue on with the attestation process
    Path 3: No EHR Certification Number in MEIPASS.
    • Log into MEIPASS
    • Enter the CMS Registration ID and click "Submit"
    • Click "Attest" and MEIPASS will navigate you to the "Eligibility Screen"
    • Input the valid EHR Certification Number and click "Add"
    • Complete the rest of the Eligibility Section
    • Click "Save" and continue on with the attestation process

    Confused or need help? Please call the NY Medicaid EHR Incentive Program Support Service at 1-877-646-5410, Option 2 or email HIT@health.ny.gov

    M05 My EHR system shows that I passed a threshold measure, but when I enter the data into MEIPASS, it says that I failed. How does MEIPASS calculate the threshold percentage?

    Published: 11/06/2018

    The data extracted from the EHR needs to either meet OR exceed the requirements of the threshold measure. MEIPASS does not round the threshold percentage. An EP should broadly calculate the percentage for the threshold to verify if the data will meet the measure requirements.

    For example, the measure for Modified Stage 2 Objective 4 Electronic Prescribing requires: More than 50% of permissible prescriptions written by the eligible professional (EP) are queried for a drug formulary and transmitted electronically using certified EHR technology. An EP may pass this measure if the threshold percentage based on numerator and denominator data is at least 50.01%. An EP will not pass this measure with a threshold percentage of 50.00%.

    Please note that if an EP is unable to meet the requirements, then the EP will need to select a different reporting period with appropriate data.

    M06 What should an Eligible Professional (EP) attest to in order to pass Stage 3 Objectives 6 and 7 for Payment Year (PY) 2019 if they have passed the thresholds for two out of the three measures and do not qualify for an exclusion from the last remaining measure?

    Published: 01/29/2020

    Stage 3 Objective 6 Coordination of Care and Objective 7 Health Information Exchange each have a set of three measures. In order to pass each objective, an Eligible Professional (EP) must attest to all three measures and pass the thresholds for two.

    For Payment Year (PY) 2019, NY Medicaid is aware that MEIPASS does not pass each of these objectives unless all three measures are satisfied (either with a passed threshold or exclusion).

    The following workaround is acceptable for any EP who passes only two out of the three measures by meeting the thresholds and does not qualify for exclusion from the last remaining measure:

    • For two measures, enter your numerator and denominator data that passes the thresholds.
    • For the third measure, enter "999" for the numerator and "999" for the denominator.
    • Click "Next" to save your data.
    • Click "Return to Meaningful Use Objectives."
    • The Objective(s) should be marked as pass with a green check mark.

    An EP should retain a copy of this FAQ in order to support their attestation for PY 2019.

1.1 How does an Eligible Provider successfully meet any of the Meaningful Use Public Health Reporting Measures?

1.1.1 Modified Stage 2 (2015-2017)

Published: 07/08/2014

Updated: 09/28/2016

Eligible Providers must register their intent to submit data to Public Health in the Meaningful Use Registration for Public Health (MURPH) System before or within 60 days of the start of one´s EHR Reporting Period. Once a registration of intent has been completed the Eligible Provider can attest "yes" for a given Public Health Reporting Measure*, if the Eligible Provider is actively engaged as demonstrated by one of the following options:

  • Option 1 - Completed Registration to Submit Data: The Eligible Professional (EP), Eligible Hospital (EH), or Critical Access Hospital (CAH) registered to submit data with the Public Health Agency (PHA) or, where applicable, the Clinical Data Registry (CDR) to which the information is being submitted; registration was completed within 60 days after the start of the EHR reporting period; and the EP, EH, or CAH is awaiting an invitation from the PHA or CDR to begin testing and validation.
  • Option 2 - Testing and Validation: The EP, EH, or CAH is in the process of testing and validation of the electronic submission of data. Eligible Providers must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within an EHR reporting period would result in that Eligible Provider not meeting the measure.
  • Option 3 - Production: The EP, EH, or CAH has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.

* Please note that if the Eligible Provider registers intent to submit data for multiple Public Health Reporting Measures that the Eligible Provider´s status for each Public Health Reporting Measure will be tracked separately and the Eligible Provider will undergo a separate onboarding process for each Public Health Reporting Measure.

1.1.2 Stage 3 (2017-2021)

Published: 09/28/2016

Updated: N/A

Eligible Providers must register their intent to submit data to Public Health in the Meaningful Use Registration for Public Health (MURPH) System before or within 60 days of the start of one´s EHR Reporting Period. Once a registration of intent has been completed the Eligible Provider can attest "yes" for a given Public Health Reporting Measure*, if the Eligible Provider is actively engaged as demonstrated by one of the following options:

  • Option 1 - Completed Registration to Submit Data: The Eligible Professional (EP), Eligible Hospital (EH), or Critical Access Hospital (CAH) registered to submit data with the Public Health Agency (PHA) or the Clinical Data Registry (CDR) to which the information is being submitted; registration was completed within 60 days after the start of the EHR reporting period; and the EP, EH, or CAH is awaiting an invitation from the PHA or CDR to begin testing and validation.

    This option allows providers to meet the measure when the PHA or the CDR has limited resources to initiate the testing and validation process. Eligible Providers that have registered in previous years do not need to submit an additional registration to meet this requirement for each EHR reporting period.
  • Option 2 - Testing and Validation: The EP, EH, or CAH is in the process of testing and validation of the electronic submission of data. Eligible Providers must respond to requests from the PHA or the CDR within 30 days; failure to respond twice within an EHR reporting period would result in that Eligible Provider not meeting the measure.
  • Option 3 - Production: The EP, EH, or CAH has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR. Eligible Providers must respond to requests from the PHA or the CDR within 30 days; failure to respond twice within an EHR reporting period would result in that Eligible Provider not meeting the measure

* Please note that if the Eligible Provider registers intent to submit data for multiple Public Health Reporting Measures that the Eligible Provider´s status for each Public Health Reporting Measure will be tracked separately and the Eligible Provider will undergo a separate onboarding process for each Public Health Reporting Measure.

1.2 When must an Eligible Provider engage with a Public Health registry in order to successfully meet Meaningful Use Public Health Reporting Measures?

Published: 09/09/2015

Updated: 09/28/2016

Eligible Providers must engage with each registry supporting the Meaningful Use Public Health Reporting Measures that the Eligible Providers intend to meet within the EHR Reporting Period for each Payment Year. Aside from registration of intent, which may be submitted prior to or within 60 days of the start of the EHR Reporting Period, all other activities required to meet the Public Health Reporting Measures must take place within the EHR Reporting Period. Actions taken after the end of the EHR Reporting Period will not count towards meeting the Public Health Reporting Measures for that Payment Year.

For example, an Eligible Professional (EP) intending to meet the Immunization Registry Reporting Measure for Payment Year 2016 must be actively engaged with the appropriate immunization registry during the EHR Reporting Period for 2016. Active engagement activities such as submission of a test performed during the 2017 calendar year would not suffice to meet the measure for Payment Year 2016.

Additional Resources:

1.5 I am looking to attest to a Public Health Reporting Measure, which registries are currently available?

Published: 08/20/2014

Updated: 12/10/19

Please see the proper payment year for the available NYS Department of Health (NYSDOH) and NYC Department of Health and Mental Hygiene (NYC DOHMH) sponsored Public Health registries:

Additional Information:

An Eligible Provider may be eligible to count engagement with a Specialized Registry as active engagement under Meaningful Use (MU) Stage 3 Public Reporting Measure or Clinical Data Registry Reporting Measure.

There are several requirements defined in the Stage 3 Final Rule (80 FR 62868) for an Eligible Provider to meet this qualification. Please see MU Stage 3 - Public Health Registry Reporting Grandfathering Regulation for additional information.

2. REGISTRATION & THE MEANINGFUL USE REGISTRATION FOR PUBLIC HEALTH (MURPH) SYSTEM

Contents

________________________________________________________________

2.1 How does an Eligible Provider register their intent to submit data and engage in testing with a Public Health registry for the Meaningful Use Public Health Reporting Measures?

Published: 09/28/2016

Updated: N/A

Eligible Providers must register their intent to submit data to Public Health in the Meaningful Use Registration for Public Health (MURPH) System before or within 60 days of the start of one´s EHR Reporting Period. A confirmation will be sent through e-mail to each Eligible Provider who registers their intent in the MURPH System.

Once a registration is received, the Public Health registries will triage new registrants and prioritize Eligible Providers based on staff/resource availability, volume of data, practice size, reporting periods and other criteria. When the Public Health registry staff is ready to work with the Eligible Provider, they will e-mail an Invitation to Test to the Registration and Alternate Contacts listed in the registration and staff will change the Eligible Provider´s status to "Invited to Test." As soon as a timely response is received, registry staff will change the status to Active Engagement Option 2 - Testing and Validation.

A timely response is defined as a response from an Eligible Provider to a registry´s Invitation to Test before the expiration of the program time limits. An Eligible Provider will be sent up to two invitations, each having a 30-day time limit. If an Eligible Provider fails to respond to the first and then second Invitation to Test before the 30-day time limits expire, then the provider will be deemed "Non-Responsive" and not a meaningful user of Certified EHR Technology.

2.2 If an Eligible Provider achieved submission of production data prior to the start of their Meaningful Use EHR Reporting Period and is currently submitting production data for a given Public Health Reporting Measure, should the Eligible Provider still register their intent in the Meaningful Use Registration for Public Health (MURPH) System?

Published: 07/08/2014

Updated: 11/10/2015

An Eligible Provider who achieved submission of production data prior to the start of their Meaningful Use EHR Reporting Period and sustains submission of production data throughout the EHR Reporting Period is strongly encouraged to register their intent in the Meaningful Use Registration for Public Health (MURPH) System. Further testing will not be required if the registry confirms that submission of production data has been achieved. By registering in MURPH, the EHR Incentive Programs will have a complete picture of Eligible Providers who are in submission of production data and can further provide the Eligible Providers with appropriate documentation to support a post-payment audit. In addition, submitting a registration will protect Eligible Providers who believe they are in submission of production data, but are assigned a status that requires registration of intent within 60 days of the start of the EHR Reporting Period.

2.4 How can information submitted in the Meaningful Use Registration for Public Health (MURPH) System be changed?

Published: 01/05/2015

Updated: 09/28/2016

If any changes are required to the registration information, the Registration and Alternate contacts listed on the registration can log back into HCS to make any update by following the steps below:

  1. Log into HCS: https://commerce.health.state.ny.us
  2. Click on "My Content" on the top navigation bar
  3. Click on "All Applications" in the drop down
  4. Click on the letter "M"
  5. Click on "Meaningful Use Registration for Public Health"
  6. Click on "Eligible Hospitals" or "Eligible Professionals", under "Register"
  7. Click on the "Edit" icon from the Actions column
  8. Make any necessary updates and click "Submit". An updated confirmation will be generated at that time.

Additional Resources:

Please see the Eligible Professional MURPH Registration Guide or Eligible Hospital MURPH Registration Guide for additional details on modifying a registration in the MURPH System.

2.5 If an Eligible Professional (EP) practices in multiple locations, what is the procedure for registering in the Meaningful Use Registration for Public Health (MURPH) system?

Published: 09/28/2016

Updated: N/A

If all practice sites are located in the same jurisdiction (i.e. all inside or all outside the five boroughs of NYC), a single practice registration should be submitted in the MURPH System. Each practice location where at least one EP is registering intent for a Meaningful Use Public Health Reporting Measure should be added to the same MURPH registration. In addition, every EP, working across all practice sites, who will be submitting data to any Public Health Registry in order to meet the Public Health Reporting Measures should also be added to the same MURPH registration.

Exception:

If all practice sites are NOT located in the same jurisdiction, then a MURPH registration will need to be submitted for the location(s) outside the five boroughs of NYC and a second MURPH registration will need to be submitted for the location(s) inside the five boroughs of NYC.

Please work with your practices to ensure duplicate registrations for an EP are not being created for the same practice location. Registering based on practice location allows the NY Medicaid EHR Incentive Program to alert the correct registries in each jurisdiction to begin onboarding.

Additional Resources:

Please see the Eligible Professional MURPH Registration Guide or Eligible Hospital MURPH Registration Guide for additional details on modifying a registration in the MURPH System.

2.6 If an Eligible Provider has multiple Certified EHR Technologies (CEHRTs), what is the procedure for registering in the Meaningful Use Registration for Public Health (MURPH) System?

Published: 09/28/2016

Updated: N/A

If an Eligible Provider has multiple CEHRTs being utilized they are not required to submit multiple registrations in the MURPH system.

  • The system allows Eligible Hospitals (EHs) to select the CEHRT being utilized for each Meaningful Use Public Health Reporting Measure.
  • The system allows Eligible Professionals (EPs) to select the CEHRT for each location listed in the MURPH registration.

Additional Resources:

Please see the Eligible Professional MURPH Registration Guide or Eligible Hospital MURPH Registration Guide for additional details on modifying a registration in the MURPH System.

2.7 Eligible Providers who registered on the Meaningful Use Registration for Public Health (MURPH) System in 2014 or 2015 are being asked to register a second time by the Meaningful Use (MU) Public Health Objective Support Team in the updated MURPH System. However, there is a CMS FAQ advising providers only need to register once. Why are Eligible Providers being asked to register a second time?

Published: 09/28/2016

Updated: N/A

An Eligible Provider who has registered intent to submit data to a public health agency on the MURPH System, during the 2014 or 2015 years, are not required to submit a new registration. However, the NY Medicaid EHR Incentive Program does highly recommend that a new registration be submitted in the current MURPH System, launched in January 2016. This will allow an Eligible Provider to readily change and update information, ensure the registries are properly notified of the Eligible Provider´s intent to submit data and provide the appropriate compliance documentation needed to support attestation or audit, and allow the MU Public Health Objective Support Team to provide the best possible service, ensuring providers are kept up to date on any program changes, deadlines, and requirements.

Please be aware that as an Eligible Provider, you are responsible for:

  • Meeting Public Health Reporting Objective onboarding deadlines such as registering intent to submit data within 60 days of the start of the EHR Reporting Period.
  • Securing documentation such as registration, testing and submission of production data confirmations from each registry to support any potential audits.
  • Saving audit documentation for up to six years after an EHR Incentive Payment is approved.

Additional Resource: CMS FAQ

2.8 Does an Eligible Provider who will be claiming an exclusion for all Meaningful Use Public Health Reporting Measures need to submit a registration in the Meaningful Use Registration for Public Health (MURPH) System?

Published: 05/11/2015

Updated: 05/12/2016

No, although the "Exclusion" option is available for each of the Public Health Reporting Measures in the MURPH System, registration is not required for an Eligible Provider who will be claiming an exclusion for all Meaningful Use Public Health Reporting Measures.

Please note that providers will need to support their eligibility to seek an exclusion in the case of an audit.

2.9 I am an Eligible Professional (EP) reporting to a Public Health Registry (PHR) or Clinical Data Registry (CDR) outside of the New York State Department of Health (NYSDOH) and New York City Department of Health and Mental Hygiene (NYC DOHMH) Public Health Agencies (PHAs) to satisfy a Meaningful Use (MU) Public Health Reporting Measure. Should I select "Yes" in the "EP Intends to Meet the Measure" drop-down list for one of the registry options in the Meaningful Use Registration for Public Health (MURPH) System?

Published: 05/11/2015

Updated: 10/27/2016

No, selecting "Yes" in the "EP Intends to Meet the Measure" drop-down list for the registries options in the MURPH System only supports reporting to the PHAs sponsored by the NYSDOH and NYC DOHMH.

Please note that the NY Medicaid EHR Incentive Program and Public Health Objective Support Teams do not provide registration, administrative onboarding, compliance, or audit support to Eligible Professionals (EPs) satisfying a Public Health Objective when leveraging a PHR or CDR outside the NYSDOH and NYC DOHMH PHAs.

Please be aware that as an EP, you are responsible for:

  • Meeting Public Health Reporting Objective onboarding deadlines such as registering intent to submit data within 60 days of the start of one´s EHR Reporting Period.
  • Securing documentation such as registration, testing and submission of production data confirmations from the respective Public Health Registry (PHR) or Clinical Data Registry (CDR) to back any potential pre-payment and/or post-payment audits.
  • Engaging and testing with the PHR or CDR to achieve the submission of production data.
  • Saving audit documentation for up to six years after an EHR Incentive Payment is approved.

Additional Resources:

2.10 Who do I contact if I experience a problem with my Health Commerce System (HCS) account?

Published: 02/06/2015

Updated: N/A

The Commerce Accounts Management Unit (CAMU) Help Desk is available for HCS user account assistance and log in assistance. The CMAU Help Desk can be reached at 1-866-529-1890 or hinhpn@health.ny.gov.

2.11 What is the CMS Registration ID and how do I locate it?

Published: 03/16/2015

Updated: 11/10/2015

The CMS Registration ID is assigned to the provider by CMS at the time of registration for the Medicare / Medicaid EHR Incentive Program. It is a 10-digit number starting with 1000 (generic example: 1000123456). If you are unable to retrieve the CMS Registration ID, you can contact the CMS Support Team at 1-888-734-6433 for further assistance.

2.12 If a provider is participating in the Quality Payment Program (QPP) under the Merit-Based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs) and they would like to actively engage with a public health agency (PHA), then where do they register their intent to participate with the PHA?

Published: 12/27/2016

Updated: 06/30/2017

Providers participating in the QPP who wish to engage with a PHA that is supported by the New York City Department of Health and Mental Hygiene (NYC DOHMH) or New York State Department of Health (NYSDOH) may register their intent on the Meaningful Use Registration for Public Health (MURPH) System, which is the same system utilized for registration of intent for the Medicaid and Medicare EHR Incentive Programs. The registration should be completed as an "Eligible Professional" and during the process, the provider will be given the option to advise which program they are participating in.

Please note that the Meaningful Use (MU) Public Health Objective Support Team is only able to provide detailed program information to providers participating in the EHR Incentive Program. Therefore, if a provider has questions on the QPP, MIPS, or APMs programs, they should reach out to CMS directly for further information at (866)288-8292, between 8:00AM and 8:00PM EST.

Additional Information:

4. MU PUBLIC HEALTH REPORTING STATUS & COMPLIANCE

Contents

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4.1 Will I receive a Registration Confirmation for each Eligible Provider? If so, how long should I save confirmations for post-payment audit purposes?

Published: 07/08/2014

Updated: 09/28/2016

An email confirmation will be sent to the Registration and Alternate Contacts whenever the registration is submitted and updated. Registration confirmations can also be viewed and printed from the Meaningful Use Registration for Public Health (MURPH) System. From the MURPH Home page, click on "Eligible Hospitals" or "Eligible Professionals", under "Register". From the Actions column, select "Original Registration Confirmation" to view the Registration Confirmation or select "Latest Registration Update Confirmation" to view the Registration Update Confirmation generated upon the latest submission. All confirmations must be saved for at least 6 years within the provider´s supporting documentation file.

Note: If the confirmation does not open, you may need to disable any pop-up blockers. The confirmation will open in a new window or tab.

Please see Post-Payment Audit Guidance for additional information.

4.3 A Public Health Registry has sent our Eligible Professional (EP) or Eligible Hospital (EH), who is currently in Active Engagement Option 2 - Testing and Validation in the Meaningful Use Public Health Reporting onboarding process, a Request for Action communication. What happens if we cannot fully comply with their request?

Published: 01/05/2015

Updated: 11/10/2015

If an appropriate action* is not taken by the EP or EH to resolve the issue within 30 days from the sent date, then another Request for Action communication will be sent to the Registration, Alternate, and/or Technical contact. If an appropriate action* is not taken by the EP or EH within 30 days from the second sent date, then the Public Health Registry is authorized to report to the EHR Incentive Programs that the EP or EH did not meet the Public Health Reporting Measure onboarding requirements within the specified EHR Reporting Period.

*Appropriate action is specific to the testing/onboarding requirements and is the determination of the Public Health Registry.

4.4 I received notification of ongoing submission from the New York State Immunization Information System (NYSIIS). However, I am currently submitting immunization data in HL7 2.3.1. Does this count as Active Engagement Option 3 - Production for the Modified Stage 2 Immunization Registry Reporting Measure?

Published: 12/11/2015

Updated: 06/29/2017

In order to attest "yes" to the Modified Stage 2 Immunization Registry Reporting Measure, an Eligible Provider must be in active engagement with a public health agency to submit immunization data. Eligible Providers can demonstrate active engagement through one of three ways:

  • Active Engagement Option 1 - Completed Registration to Submit Data
  • Active Engagement Option 2 - Testing and Validation
  • Active Engagement Option 3 - Production

In order to achieve Active Engagement Option 3 - Production, an Eligible Provider must be submitting production data in HL7 2.5.1. While Eligible Providers submitting production data in HL7 2.3.1 cannot attest to Active Engagement Option 3 - Production, an Eligible Provider who has registered intent to submit data within 60 days of the start of the EHR Reporting Period and is awaiting an invitation from NYSIIS to begin testing and validation has achieved Active Engagement Option 1 - Completed Registration to Submit Data and may still attest "yes" to the Immunization Registry Reporting Measure.

Additional Resources:

4.5 How does an Eligible Provider determine if they are compliant with submission of production data?

Published: 07/08/2014

Updated: 11/10/2015

NY Medicaid EHR Incentive Program defines submission of production data as an Eligible Provider who continuously and successfully submits structured, production-level data from a Certified EHR Technology to the appropriate Public Health registry when the data is made available by the Certified EHR Technology and according to the timing and frequency determined by Public Health Law or registry policies.

Submission of production data is initially achieved when the Eligible Provider completes testing and validation and the Public Health registry staff determines the Eligible Provider´s live data is being received by the registry and is correct in structure and content. When submission of production data is achieved, the Eligible Provider´s status will be changed from Active Engagement Option 2 - Testing and Validation to Active Engagement Option 3 - Production. Email communications between the registry and the Eligible Provider indicating that submission of production data has been achieved is considered the Eligible Provider´s acknowledgment of this status.

Additional Details

  • Verifying that structured data is continuously being submitted successfully is the responsibility of the Eligible Provider
  • If the data is not being submitted successfully, it is the responsibility of the Eligible Provider, with assistance from the Public Health registry, to remediate the issues to maintain the status of Active Engagement Option 3 - Production

4.6 I downloaded an audit report card from MURPH. What does the onboarding status mean?

Published: 06/28/2019

NY Medicaid EHR Incentive Program has developed the Meaningful Use Registration for Public Health (MURPH) Onboarding Status Quick Reference Guide that explains all of the statuses for Onboarding and Not Currently Onboarding. For a description of the "Not Onboarding Status" with general guidance on next steps, please see the MURPH Onboarding Status Quick Reference Guide.

4.7 For a Public Health Reporting measure, do I attest "Yes" to active engagement if my Audit Report Card from MURPH shows an onboarding status of "Not Currently Onboarding?"

Published: 06/28/2019

The Centers for Medicare and Medicaid Services (CMS) advises that Eligible Provider (EP/EH) pre-attestation determinations should not be specifically made by Public Health. The attestation determination of "yes" for the public health measure is the responsibility of the EP or EH based on their interpretation of their active engagement status for any given Public Health Registry. For more information or specifics on a status, please reach out to the registry in question.

  • MURPH Contact Change Request Form (PDF)
  • Eligible Professional MURPH Registration Guide (PDF)
  • Eligible Hospital MURPH Registration Guide (PDF)
  • Eligible Professional MURPH Registration Video Guide (youtube.com) - Transcript
  • Eligible Hospital MURPH Registration Video Guide (youtube.com) - Transcript
  • MURPH Audit Report Card User Guide (PDF)
  • MURPH Onboarding Status Quick Reference Guide (Web)

2021 Meaningful Use MEIPASS Tutorial Series

Part 1: Beginning the Attestation Process Tutorial (YouTube)

This interactive, on-demand tutorial provides step-by-step guidance on completing the Eligibility portion of a 2021 Meaningful Use attestation in the MEIPASS System.

Part 2: Understanding the 50/50 and 80/20 Rules Tutorial (YouTube)

This interactive, on-demand tutorial provides step-by-step guidance on understanding the 50/50 and 80/20 rules when completing a 2021 Meaningful Use attestation.

Part 3: Attesting to Stage 3 Meaningful Use Tutorial (YouTube)

This interactive, on-demand tutorial provides step-by-step guidance on attesting to 2021 Stage 3 Meaningful Use in the MEIPASS System.

Part 4: CQM Reporting Tutorial (YouTube)

This interactive, on-demand tutorial provides step-by-step guidance on reporting Clinical Quality Measures (CQMs) in the MEIPASS System.

Part 5: eSignature & Attestation Submission Tutorial (YouTube)

This interactive, on-demand tutorial provides step-by-step guidance on eSignature and attestation submission in the MEIPASS System.

A MEIPASS Attestation Walkthrough (PDF) is also available.

Understanding Reporting Periods Tutorial (YouTube)