Meaningful Use: Registration and Attestation
Providers must register for the EHR Incentive Program and then attest to meeting all of the requirements. Both of these are accomplished via the Medicare and Medicaid EHR Incentive Program Registration and Attestation System.
When to Register:
Eligible Professionals (EPs) can register any time prior to—or at the same time as—attestation. EPs only have to register once for the duration of the program, unless they want to change any of their information or switch from one program to another, (i.e., Medicare vs. Medicaid Incentives).
- National Provider Identifier (NPI)
- National Plan and Provider Enumeration System (NPPES) web user account
- NPPES user ID and password are used to log in to the registration system
- Selection of Medicare or Medicaid incentives program
- For Medicare providers, enrollment in the Provider Enrollment, Chain, and Ownership System (PECOS) is required
- For Medicaid providers, select your state and continue on its EHR Incentives site (Note: You can switch programs only once after receiving a payment.)
- Personal Information
- Social Security Number
- Taxpayer ID to which incentive payment should be made, i.e., EP’s SSN or Group’s EIN (Note: EP can receive the payment directly only if he/she has not reassigned Medicare benefits in PECOS.)
- Business information
- Populated from NPPES, but EPs can make changes if desired
- EHR Certification Number
- Optional at registration, required at attestation
How to Authorize a Surrogate to Attest for EP:
In response to numerous requests from the provider community, CMS allows physicians to assign a third party to complete the registration and attestation process for them, i.e., “work on behalf of the EP.” This person must have an Identity and Access (I&A) management system web user account (user ID and password) and be associated to the EP’s NPI. There is a link to create a login for the I&A system within the EHR Incentives registration process.
- CMS Registration Video – walks step-by-step through the registration process
- CMS Registration Page
- CMS Registration User Guide for the Medicare EHR Incentive Program
- CMS Registration User Guide for the Medicaid EHR Incentive Program
Attestation is the process by which Eligible Professionals (EPs) report to CMS that they have met the measures required to demonstrate meaningful use and therefore qualify for the incentive payment. EPs attest on the Medicare and Medicaid EHR Incentive Program Registration and Attestation System—the same system used for registration.
When to Attest:
EPs attest at the conclusion of each reporting period. At the end of the attestation process, EPs are advised whether their attestation is accepted (i.e., successful) or rejected. EPs whose attestation is rejected can attest again, but it must be for a different 90-day period.
- Attestation Information
- CMS EHR Certification ID# (CHPL Website) created on the Certified Health IT Product List (CHPL Website)
- Reporting Period
- Meaningful Use Core Measures – report on all 15
- Meaningful Use Menu Measures – select 5 of the 10 measures
- Core Clinical Quality Measures – report on 3
- Alternate Core Clinical Quality Measures – if needed to replace any of the 3 Core CQMs on which EP reports “0”
- Additional Clinical Quality Measures – select and report on 3 of 38
What to Report:
Depending on the measure, EPs will be asked to attest:
- Whether they are reporting based on all patient records or only those maintained in their EHR
- Whether any exclusion—if available—applies to them; if no exclusion applies, then EPs must either:
- Provide numerator and denominator for the measure, or
- Attest that EP has taken the required action, e.g., enabled the functionality, conducted a test, generated a report, etc.
- That data submitted for clinical quality measures was generated as output from the identified certified EHR technology
Before attesting, EPs should use the CMS Meaningful Use Attestation Calculator worksheet to verify that they have successfully met all of the requirements.
- CMS Attestation User Guide – Stage 1
- CMS Attestation User Guide – Stage 2
- CMS Guidance on Supporting Documentation for Meaningful Use Audits