State medicaid HIT plan (SMHP) : CMS letter - 9/3/2010, enclosure A

              STATE OF OKLAHOMA
OKLAHOMA HEALTH CARE AUTHORITY
STATE MEDICAID HIT PLAN
(SMHP)
VERSION 2.0
CMS Letter - 9/3/2010
Enclosure A
October 13, 2010
This page intentionally left blank.
State of Oklahoma
Oklahoma Health Care Authority
State Medicaid HIT Plan (SMHP)
CMS Letter 9/3/2010 Enclosure A
October 13, 2010 Page 1
1 SMHP REVISION
This State Medicaid Health Information Technology (HIT) Plan (SMHP) Revision addresses the
questions raised in the Centers for Medicare & Medicaid Services (CMS) letter dated
September 3, 2010, and addenda. The CMS questions are noted below with relevant SMHP
sections and revised text provided. All revisions are provided in the order of the question
received from CMS and highlighted in bold italics to facilitate review. Future changes to this
SMHP will be published in SMHP section order.
Global changes to the SMHP included:
1. “SoonerCare Electronic Health Record (EHR) Incentive Program” is changed to
“Oklahoma EHR Provider Incentive Payment Program” throughout the SMHP.
2. Global search was conducted for “proposed rule” and revised to “Final Rule,” where
appropriate.
State of Oklahoma
Oklahoma Health Care Authority
State Medicaid HIT Plan (SMHP)
CMS Letter 9/3/2010 Enclosure A
October 13, 2010 Page 2
CMS Question 1: Please describe whether and how tribal facilities were included in the
environmental scan. Also, include other stakeholder groups, (e.g., family planning, clinics,
mental health, long-term care, pharmacies, etc.).
Response: See below in Section 2.5.4. Paragraphs 1, 3, and 6 are added as shown. In Section
2.5.5, a sentence is added to paragraph 1 to address ineligible provider types.
Section 2.5.4 Indian Health Service (IHS)/Tribal facilities/Urban Indian Clinic
(I/T/U) Providers
Oklahoma Health Care Authority’s (OHCA) Indian Health Unit serves as a liaison between
OHCA and tribal governments with the goal of improving services to American Indian
SoonerCare members and providers by increasing access to health care, advancing
ongoing and meaningful communication, and maximizing partnerships.
Early on OHCA explored with I/T/U partners whether their providers would be eligible for
participation in the federal Provider Incentive Program. Once it was clear that they could, the
OHCA Indian Health Unit targeted these providers with the 10-question eligible professional
(EP) follow-up scan. IHS and tribal hospitals were provided the eligible hospital (EH) scan.
To maximize outreach to this population, the OHCA Indian Health Unit personally
contracted all I/T/U EPs and EHs to educate, obtain input and validate lists of potentially
eligible providers, and later to survey the provider about their facility and their use of
EHRs.
The Indian Health Unit worked directly with the OHCA planning and development committees to
ensure consultation and inclusion of IHS, Tribal facilities and Urban Indian Clinics in Oklahoma.
The Indian Health Unit each contracted Indian health facility by telephone or email, including
Tribal facilities, Urban Indian facilities, IHS facilities, and the Oklahoma City Area IHS
Administrative Office.
Each contracted site was personally contacted by one of the staff of OHCA Indian Health Unit to
educate, get input, and obtain lists of their potentially eligible providers and later to survey the
provider about their practice and their use of EHRs. OHCA Indian Health Unit worked with I/T/U
facilities one-on-one to inform them of the initiative and how it might impact them. I/T/U staff was
given the opportunity to ask questions, identify contacts within their tribe and arrange follow-up
meetings or conference calls, etc., with OHCA if they had additional questions.
Of 677 surveys mailed, 475 were returned, most through the administrative offices of
I/T/U facilities. This seemed to indicate that many I/T/U EPs and EHs were aware of this
opportunity. Additional efforts included giving numerous presentations to the Oklahoma
City Area IHS Administrative Office and Oklahoma City Area Inter-Tribal Health Board.
The OHCA Indian Health Unit also produced a written summary of the Oklahoma EHR
Provider Incentive Payment Program to all Tribal facilities, Urban Indian Health facilities,
and IHS facilities. Future opportunities for outreach include the 4th Annual Tribal
Consultation as well as SoonerCare provider training this fall. OHCA will also provide
presentations to I/T/U providers upon request.
State of Oklahoma
Oklahoma Health Care Authority
State Medicaid HIT Plan (SMHP)
CMS Letter 9/3/2010 Enclosure A
October 13, 2010 Page 3
Section 2.5.5 Selection of Environmental Scan Participants
This section will describe how the environmental scan population was selected and demographics about the selected providers
(statewide, eligible providers, hospitals, Health Information Exchange (HIE) networks) and provider specialties, etc.
OHCA elected to scan all currently contracted SoonerCare providers that were of the type
considered eligible for the Oklahoma EHR Provider Incentive Payment Program under the
proposed rule: Physician, Pediatrician, Nurse Practitioner, Certified Nurse Midwife, and Dentist,
and all EHs in the State. Ineligible provider types such as family planning, clinics, mental
health, long-term care, and pharmacy providers were not scanned. OHCA identified 6,199
individual and group providers and 130 hospitals, (which included 6 IHS hospital facilities).
Ninety-three Federally Qualified Health Centers/Rural Health Centers (FQHCs/RHCs) were also
identified. As Oklahoma is largely a rural State, extra efforts were made to ensure that scans
reached and were responded to by small and rural providers. Focus of the scans remained on
in-state providers.
CMS Question 2: Since the majority of the State’s Medicaid population is enrolled in a
managed care program, please confirm that the State will be able to provide payments to all
EPs affiliated with this program, including a description of the payment process that will used
(i.e., all payments through Medicaid Management Information System (MMIS) and/or other
means).
Response: A new paragraph is added to Section 4.6 as shown below.
Section 4.6 Processing Payments to Providers
This section includes the plan for making payments to providers and a list of tasks that must be completed during the
implementation phase to calculate and process provider payments. Appendix E contains the Table of Qualifying Patient Volume.
“SoonerCare” is Oklahoma’s Medicaid 1115(a) waiver program and is not entirely a
managed care program. One of eight plans (SoonerCare Choice) is considered managed
care. SoonerCare Choice operates under a Primary Care Case Management (PCCM)
model in which the OHCA contracts directly with primary care providers throughout the
State to provide basic health care services. Oklahoma’s Children’s Health Insurance
Program (CHIP) members are seamlessly integrated into the SoonerCare Choice
program. All the other eight medical program services in the demonstration, with the
exception of emergency transportation which is paid through a capitated contract, are
paid through the State’s Fee For Service (FFS) system. For the duration of the Oklahoma
EHR Provider Incentive Payment Program, all incentive payments to EPs and EHs will be
processed through the MMIS.
CMS Question 3A: The State indicates on page 47 of the SMHP that it will not accept
meaningful use (MU) data until 2012. Please clarify whether the State will be able to accept MU
attestations in 2011.
Response: See below in Section 3.2. The text in Third paragraph has been amended as shown.
State of Oklahoma
Oklahoma Health Care Authority
State Medicaid HIT Plan (SMHP)
CMS Letter 9/3/2010 Enclosure A
October 13, 2010 Page 4
Section 3.2 Vision for HIT Environment
This section will include a description of OHCA assumptions and where the path and timing of their plans have dependencies based
upon State-specific readiness factors.
Oklahoma will not accept from dual Medicare/Medicaid providers attestations of meeting
MU through our attestation system butwill not be able to accept the meaningful use
measurement results through that system. Upon approval of the MU chapter of the
Implementation Advance Planning Document (IAPD), OHCA will devise a method to
accept the actual results of the MU measures for analysis and reporting in other formats.
OHCA will accept MU data and integrate this information into the new system when it
becomes available from providers who wish to submit it.
CMS Question 3B: Additionally, starting on page 14, “OHCA will use the meaningful use
measures identified in the Final Rule for the first year of the program.” This statement does not
agree with statements above. Please correct this issue and clarify when the State will use the
MU measures defined in the final rule.
Response: See below in Section 1.1.3. The text in the paragraph 13 has been amended as
shown.
Section 1.1.3 Provider Incentive Program Implementation
OHCA will use the MU measures identified in the Final Rule for the first year of the program
upon implementation of the MU chapter of our IAPD.
CMS Question 4: Starting on page 56, electronic verification of eligibility is not a final rule MU
objective. Public health reporting is limited to testing for Stage one, not submission of reports.
Therefore, OHCAs target exceeds MU. Please be clear about what are OHCA targets versus
expectations for providers.
Response: See below in Section 3.2. The last two rows of Table 6 have been deleted as shown.
Table 1 Performance Measures for SoonerCare Provider HIE Participation
Performance measure Metric Method and Data
sources
Initial target
Percent of providers
participating in HIE services
enabled by statewide
directories or shared
services
Percent of
providers using
shared services
Number of providers
with logins to shared
services each month
divided by the total
number eligible to use
shared services
40% participation in
OKHIE at year 2
Percent of pharmacies
serving people within the
State that are actively
supporting electronic
prescribing and refill
requests
Percent of new
scripts that are
electronic
Percent of refill
requests that are
electronic
Number of scripts
written electronically
divided by the total
number of scripts filled
Number of refill requests
submitted electronically
to providers by
40% of scripts should
be electronic by end of
year 2 participation in
OKHIE.
40% of refill requests
should be electronic by
the end of year 2
State of Oklahoma
Oklahoma Health Care Authority
State Medicaid HIT Plan (SMHP)
CMS Letter 9/3/2010 Enclosure A
October 13, 2010 Page 5
Performance measure Metric Method and Data
sources
Initial target
pharmacies divided by
the total number of refills
completed
participation in OKHIE
Percent of clinical
laboratories serving people
within the State that are
actively supporting
electronic ordering and
results reporting
Percent of lab
tests ordered
electronically
Percent of lab
results delivered
electronically
Number of lab tests
ordered electronically
divided by the total
number of lab tests
ordered
Number of lab test
results delivered
electronically divided by
total number of lab tests
Once OKHIE is
established the target
for SoonerCare
providers is: 40%
ordered electronically
95% of test results
delivered electronically
in Year 2
Provider participation in HIE
by MU requirement met
Identity of
providers who
demonstrate MU
Percent of
providers
demonstrating MU
by requirement
Given finalized list of
requirements, the HIE
will be used to assess
the number and identity
of providers who meet
relevant MU criteria
Once OKHIE is
established, the target
for SoonerCare
providers is: 40% of
providers meet MU
criteria in Year 2
Electronic exchange of
clinical summaries
Percent of clinical
summaries
available
electronically
Number of clinical
summaries in HIE
divided by the total
number of encounters
documented
25% available
electronically by the
end of year 2
participation in OKHIE
Immunizations available via
HIE
Percent of
childhood and
adult
immunizations
documented
electronically and
available in HIE
Percent of
providers
documenting
immunization
administration
electronically
Number of immunization
administrations available
electronically divided by
the total need for
vaccines.
Number of providers
entering immunization
administrations each
month divided by the
total number of
providers in the State
Once OKHIE is
established, the target
is 99% of immunization
records available
electronically by the
end of year 2 and 80%
of providers
documenting
immunizations
electronically by the
end of year 2
Eligibility checking Percent of
providers using
electronic
eligibility checking
Number of electronic
eligibility checks divided
by the total number of
eligibility checks
60% of eligibility
checks electronic by
end of year 2
participation in OKHIE
Public health reporting Percent of reports
to State and local
public health
agencies
Number of electronic
reports to public health
agencies of vital
statistics, reportable
50% of reports via
electronic means by
the end of year 2
participation in OKHIE
State of Oklahoma
Oklahoma Health Care Authority
State Medicaid HIT Plan (SMHP)
CMS Letter 9/3/2010 Enclosure A
October 13, 2010 Page 6
Performance measure Metric Method and Data
sources
Initial target
occurring
electronically
conditions, etc. divided
by total number of
reports
CMS Question 5: Starting at page 48, please include additional detail concerning how the State
will interface and verify this information
Response: Section 3.2 Registration and Attestation is revised in its entirety as shown.
Registration and Attestation
OHCA has as part of its MMIS, a web-based electronic provider enrollment (EPE). The EPE
system will be modified to accommodate registration and attestation data related to the
SoonerCare Oklahoma EHR Provider Incentive Payment Program.
When OHCA receives a transaction from the National Level Repository (NLR) indicating
that a provider has registered for the Oklahoma SoonerCare EHR Provider Incentive
Payment Program, a transaction will be stored in a database in the MMIS for record
tracking. Two basic validations will be made: 1.) validate the National Provider Identifier
(NPI) in the transaction is on file in our MMIS Provider database, 2.) validate the provider
is currently contracted with OHCA. If either of these conditions is not met, a “provider
not eligible” status will be automatically sent back to the CMS NLR.
OHCA will publish on its public website and on our provider secure site, information
regarding how to use the EPE system to submit an attestation for the Oklahoma EHR
Provider Incentive Payment Program and advise what information and documentations
the provider will need in order to: 1.) participate in the Oklahoma EHR Provider Incentive
Payment Program, and 2.) meet attestation requirements to qualify for the incentive
payment. send the provider information regarding how to log into the EPE system and
advise what information and documentation the provider will need in order to (1) register
in the SoonerCare EHR Incentive Program and (2) meet attestation requirements to
qualify for their incentive payment.
During the registration and attestation process, basic eligibility criteria, such as verification of
provider NPI and taxpayer identification number (TIN), provider type, NLR status and both
federal and local sanctions will be verified using EPE. Only currently contracted providers
can login to the EPE Provider Portal. The link for the EHR attestation function will only be
displayed to professional provider and hospital types as designated by CMS. The
Oklahoma EHR attestation process will first request the provider to enter their CMS
Registration number, and this number will be compared to the NLR transactions on file
locally in our MMIS. If the number is found, the NPI in the NLR Registration transaction
will be compared to the provider’s NPI number associated with their login. The NLR
payee TIN will also be compared to the TIN numbers associated with the provider and
his/her group TINs. Any sanctions/exclusions provided in the NLR transaction will be
addressed manually.
State of Oklahoma
Oklahoma Health Care Authority
State Medicaid HIT Plan (SMHP)
CMS Letter 9/3/2010 Enclosure A
October 13, 2010 Page 7
Providers that do not meet the requirements for the program will be informed of the specific
issues that affect their eligibility and the process for redress.
The MMIS/EPE system will be updated manually after eligibility verification, to reflect the
provider’s positive or negative eligibility. This will trigger a registration eligibility
response transaction (B-7) update to the CMS NLR. In addition, when eligibility and all
supporting documentation has been received and verified, a duplicate payment inquiry
will be sent to the CMS NLR.
CMS Question 6: Starting at page 75, please confirm that “Acute Care hospital means any
provider with a provider specialty of 010 – Acute Care Hospital or 016 – IHS Hospital” will
include/match up with all of the hospitals CMS designated. (Note the only registrations the State
will receive from the NLR include hospitals with the correct CCNs, so the State will be
responsible for ensuring that the Average Length of Stay is 25 days or fewer),
Response: Section 4.5.1.3 second paragraph and bullet #7 are amended as shown.
A sentence is added to Section 4.5.1.5 paragraph 1 to indicate how OHCA plans to monitor
Critical Access Hospitals (ACHs) to ensure only admissions with an average length of stay of 25
days or less. Attestation statement is added to Table 10 in Section 4.6.1 (shown in Question #
11 below) to ensure only admissions with average length of stay 25 days or fewer are included
when determining patient volume.
Section 4.5.1.3 Eligible Provider Types
Specifically, the SoonerCare Oklahoma EHR Provider Incentive Payment Program
Registration component of the EPE web site will be limited to the following MMIS provider types,
which will include all of the hospital and professional provider types designated by CMS:
  Acute Care hospital = Any provider with a provider specialty of 010 – Acute Care
Hospital; or 016 – IHS Hospital, or 014 ��� Critical Access Hospital
Section 4.5.1.5 Verifying EP Patient Volume
Claims data from OHCAs DW will be used to verify the reasonableness of patient volume
attested to by EPs and to ensure CAHs average length of stay is 25 days or fewer. EPs will
be asked to provide separate patient volume numbers from each of the different locations
associated with their NPI. This will help in two ways: 1) Practice owners/managers at one
location will not be able to complete the EPs attestation for all practices and therefore, will not
be able to complete the attestation and assign payment to their location without the EPs
knowledge and 2) The patient volume numbers will be easier to validate at the location level
than in the aggregate.
CMS Question 7: Starting at page 75, with the term “meets a SoonerCare patient volume.” The
Medicaid patient volume requirements are not specific to just a portion of the State’s program.
Please clarify in your definition of patient volume that all Medicaid clients (SoonerCare, FFS,
other) will be included in the calculation.
Response: Section 4.5.1.4 paragraph 2 has been added as shown below.
State of Oklahoma
Oklahoma Health Care Authority
State Medicaid HIT Plan (SMHP)
CMS Letter 9/3/2010 Enclosure A
October 13, 2010 Page 8
CMS Question 8: Starting at page 78, with patient volume (Medicaid and NPI). Please clarify
which option the State is using. It appears that to be the FFS option (non-consideration of
patient panels), but also refers to SoonerCare. CMS recommends that the State consider
combining the two options in order to maximize participation.
Response: Section 4.5.1.4 shown in entirety adds paragraphs 1, 2, 3, and bullet #1.
Section 4.5.1.4 Methodology for EP Patient Volume
SoonerCare Choice is a Partially Capitated Case Management managed care model. This
population is enrolled in a Patient Centered Medical Home. Patient panel methodology
will not be utilized. SoonerCare encounters are identified below:
For SoonerCare patient volume calculations, all populations, except CHIP members
enrolled in the SoonerCare Choice Program, are considered to be Medicaid recipients,
are SoonerCare members, and may be used in the numerator to the SoonerCare Patient
formula ratio. Additionally, SoonerCare providers may count non-SoonerCare out-of-state
Medicaid recipients, if properly documented, in the numerator of the patient volume
ratio. The OHCA will participate in a CMS Region VI multi-state collaborative meeting
October 19 – 22, 2010, to lay the framework for state to state data sharing.
Identification of CHIP members is a significant issue. SoonerCare members who receive
services paid by Title XXI are seamlessly integrated through the Medicaid 1115 (a)
waiver, as a demonstration population in the SoonerCare Choice program (see response
to CMS Question 2). Due to this integration, it is impossible for EPs and EHs to
distinguish between patients receiving medical assistance under Title XIX versus Title
XXI. The SoonerCare membership card does not distinguish between SoonerCare
programs nor does the remittance advice report distinguish which funding sources paid
for members’ claims. Additionally, the State does not habitually generate reports down to
that level of fidelity necessary to show the fund code/program code used to pay a claim
to a SoonerCare provider.
OHCA has adopted the Final Rule CMS patient volume definition for the Oklahoma EHR
Provider Incentive Payment Program. The following statements encapsulate the CMS Final
Rule definition regarding patient volume:
  …The regulation at 495.306(e) states that a Medicaid encounter will exist where
Medicaid (or Medicaid demonstration project approved under section 1115) paid
for part or all the service; or where Medicaid (or a Medicaid demonstration project
approved under section 1115) paid all or part of the individual’s premiums, co-payments
and/or cost-sharing. Because the methodology is based upon Medicaid
payment for an encounter, and because it will be difficult or impossible for EPs
and EHs to distinguish between payment that is due to expansion populations
(who are not receiving title XIX medical assistance), Providers will be allowed to
include in the patient volume calculation individuals who are part of expansion
populations under section 1115 (a) (2) of the Act. (Source: Final Rule page 540.)
  “… all EPs and the vast majority of hospitals will need to meet certain patient volume
thresholds in order to be eligible for incentive payments. (The only exception to this rule
is for children’s hospitals, which have no patient volume threshold requirement)…
State of Oklahoma
Oklahoma Health Care Authority
State Medicaid HIT Plan (SMHP)
CMS Letter 9/3/2010 Enclosure A
October 13, 2010 Page 9
  …for the SoonerCare member volume, these thresholds are calculated using as the
numerator the individual hospital’s or EPs total number of SoonerCare member
encounters in any representative continuous 90-day period in the preceding calendar
year and the denominator is all patient encounters for the same individual professional
or hospital over the same 90-day period.”
  EPs practicing predominantly in an FQHC or RHC must have a minimum of 30%
patient volume attributable to needy individuals as defined as §495.302 and will be
evaluated according to their “needy individual” patient volume. To be identified as a
“needy individual,” patients must meet one of following criteria: (1) received medical
assistance from SoonerCare or the CHIP; (2) Were furnished uncompensated care by
the provider; or (3) Were furnished services at either no cost or reduced cost based on a
sliding scale determined by the individual’s ability to pay.
Table 2 SoonerCare Patient Volumes
EH Type Patient Volume over 90-day Period
Acute Care Hospital 10%
Children’s Hospital No percentage requirement
EP Type Patient Volume over 90-day Period
Physicians (M.D., D.O.) o 30% SoonerCare
o For Medicaid EPs in FQHC/RHC - 30%
Needy Individuals
Dentists
Certified Nurse Midwifes
Nurse Practitioners
PAs in FQHC/RHC led by a
Physician Assistant (PA)
Pediatricians o 30% SoonerCare
o If Pediatrician patient volume = 20-29%,
the provider may qualify for 2/3 of
incentive payment
CMS Question 9: Starting at page 77, Hospital-Based EPs, please clarify whether the State
plans to utilize any encounter data to make this determination.
Response: OHCA replaces the second sentence of Section 4.5.1.6 as shown.
Section 4.5.1.6 Assuring Providers Are Not Hospital-Based
OHCA will ask providers to attest that they are not hospital-based. In addition, EP paid claims
data for the reporting period will be analyzed with the provider’s NPI in the rendering provider
field to determine the place of service for their claims. Since the definition of “hospital based”
now includes inpatient or ER setting, OHCA plans to use only Place of Service Codes 21-
State of Oklahoma
Oklahoma Health Care Authority
State Medicaid HIT Plan (SMHP)
CMS Letter 9/3/2010 Enclosure A
October 13, 2010 Page 10
Inpatient Hospital and 23-ER as a basis for “hospital-based” services. Analysis will be made of
professional and institutional claims (and dental claims, for dental providers) to verify where
their SoonerCare member time is spent. If the predominant place of service is at the inpatient
hospital or ER, OHCA will consider the provider to be hospital-based.
CMS Question 10: Starting at page 79, “EPs and EHs enrolling in Oklahoma EHR Provider
Incentive Payment Program must have a practice physically located within Oklahoma.”
Technically, the State may not make requirements like this, but you can say that they must have
a valid payment relationship established. For example, if a provider had a practice just over the
border, but still served 30 percent Oklahoma Medicaid – they may participate (and with 30
percent Medicaid, you are assured that you already have a payment relationship with the
provider). Another example is that providers practicing predominantly just have to meet the
program requirements, but do not have to have a practice anywhere in particular.
Response: Section 4.5.2 has been amended as shown.
Section 4.5.2 Eligible Providers
This section will identify hospitals and providers eligible to enroll in the Oklahoma PIP.
OHCA will qualify providers as defined in the Final Rule Medicare and Medicaid Programs;
EHR Incentive Program. As specified under section 1903(t)(2)(A) of the Act, SoonerCare
participating providers who wish to receive a Medicaid incentive payment must meet the
definition of a “Medicaid EP’’, “Medicaid EH” or “Critical Access Hospital.” The EP definition
(1903(t)(3)(B) of the Act) lists five types of Medicaid professionals: Physicians, dentists, certified
nurse-midwives, nurse practitioners, and physician assistants practicing in an FQHC or RHC
that is so led by a physician assistant. OHCA also engaged I/T/U and determined that I/T/U
providers that meet the eligibility criteria could also participate in the program.
All EPs and EHs enrolling in SoonerCare Oklahoma EHR Provider Incentive Payment
Program must have a contract to provide services to SoonerCare members.
A condition of eligibility for the Oklahoma EHR Provider Incentive Payment Program is a
valid SoonerCare provider contract. This establishes the payment relationship for
providers who would bill directly for services rendered. SoonerCare contracts are
generated using an online web application which will electronically enroll providers once
necessary documentation has been faxed to OHCA. For purposes of attestation to the
requirements of the incentive program, we have developed a SoonerCare contract
amendment which will be electronically submitted and approved upon receipt of faxed
support documentation.
For purposes of verifying patient volume prior to payment, OHCA will perform business
queries to our MMIS and using paid claims data associated with the specific provider,
determine the reasonableness of the provider patient volume. In the case of providers
who are not physically located in the State but have a SoonerCare contract or in-state
providers who are using Medicaid patients from another state to achieve their patient
volume requirements, OHCA will suspend the incentive payment until verification of
Medicaid encounters is made through collaboration with the provider’s home state
State of Oklahoma
Oklahoma Health Care Authority
State Medicaid HIT Plan (SMHP)
CMS Letter 9/3/2010 Enclosure A
October 13, 2010 Page 11
Medicaid agency and the appropriate documentation is manually analyzed to ensure
patient volume requirements have been achieved.
Out of state providers without a valid SoonerCare contract who register on the NLR and
elect to participate in Oklahoma’s EHR Provider Incentive Payment Program will be
considered ineligible until the out of state provider has a valid SoonerCare provider
contract. Multi-state collaboration and data sharing will be used to verify non-
SoonerCare out of state Medicaid recipient encounters. The OHCA will participate in a
CMS Region VI multi-state collaborative meeting October 19 – 22, 2010, to lay the
framework for state to state data sharing.
CMS Question 11: Starting at page 82-84, attestations. Please add clarifying language that
describes which attestations are required when a hospital is dually-eligible for Medicare and
Medicaid incentives.
Response: Section 4.6.1 is shown in its entirety. Paragraph 3 has been added under Table 9 in
SMHP and Table 10 has been updated to clarify which attestations are required for dually
eligible EHs.
Section 4.6.1 Provider Registration and Payment Request
Providers (EPs, EHs, and CAHs) contacting OHCA regarding the SoonerCare Oklahoma EHR
Provider Incentive Payment Program payment process will be directed to the OCHA secure
provider web site for detailed information on participation in the SoonerCare EHR Incentive
Program in Oklahoma. Providers will be instructed to register in the NLR before requesting
payment from OHCA.
OHCA is leveraging capability to have providers electronically engage with OHCA. OHCA is
modifying the design and requirements to match NLR and Office of National Coordinator
certification web service and screen designs are available upon request.
Providers (EPs, EHs, and CAHs) are directed to the EPE site to begin SoonerCare Oklahoma
EHR Provider Incentive Payment Program registration. OHCA will validate the SoonerCare
provider enrollment and the NLR record, affirming that the provider has selected Oklahoma
SoonerCare participation. The provider is then directed to the Oklahoma secure EPE Attestation
page where he/she will enter his/her NLR Registration number. The Attestation process will
search for the NLR Registration number in the NLR table. The Attestation process will
automatically compare the provider type, NPI, and payee TIN to the information from the NLR. If
these do not match, the user will receive an error message on the screen with an OHCA phone
number to call for assistance. The Attestation process will compute the current participation year
based on the most recent NLR Registration record participation year and the number of
participation/payment years recorded in the Oklahoma MMIS.
Table 9 EP Attestations
During EHR Year 1 reporting period, the EP
attests:
During EHR Years 2 through 6 reporting
period, the EP attests:
The EP is a board certified Pediatrician, if
applicable
The EP is a board certified Pediatrician, if
applicable
State of Oklahoma
Oklahoma Health Care Authority
State Medicaid HIT Plan (SMHP)
CMS Letter 9/3/2010 Enclosure A
October 13, 2010 Page 12
During EHR Year 1 reporting period, the EP
attests:
During EHR Years 2 through 6 reporting
period, the EP attests:
The Physician Assistant attest that he/she is
working in an FQHC or RHC so led by: a) a PA as
the primary provider in the clinic, b) a PA as the
clinical or medical director at a site of practice, or
c) a PA as an owner of an Rural Health Clinic
The Physician Assistant attest that he/she is
working in an FQHC or RHC so led by: a) a PA as
the primary provider in the clinic, b) a PA as the
clinical or medical director at a site of practice, or
c) a PA as an owner of an RHC
The EP attests that he/she practices
predominantly in an FQHC or RHC, if applicable
The EP attests that he/she practices
predominantly in an FQHC or RHC, if applicable
The EP is not Hospital based professional who
furnishes 90% or more of his/her professional
services in an inpatient hospital or emergency
room setting, if he/she does not practice
predominantly in an FQHC or RHC
The EP is not Hospital based professional who
furnishes 90% or more of his/her professional
services in an inpatient hospital or emergency
room setting, if he/she does not practice
predominantly in an FQHC or RHC
The EP is not concurrently receiving an incentive
payment from another state, or under another
SoonerCare ID number or Medicare program
The EP is not concurrently receiving an incentive
payment from another state, or under another
SoonerCare ID number or Medicare program.
The EP has adopted, implemented or upgraded
(A/I/U) a certified EHR
The EP used certified EHR technology
The EHR product used is certified and EP entered
a product certification number
The EHR product used is certified and EP entered
a product certification number
The EP has reported the number of Full Time
Equivalent (FTE) jobs created by implementing
this certified EHR product
The EP has reported the number of FTE jobs
created by implementing this certified EHR
product
The EP has reported the amount of cash
payments made directly attributable to him/her for
the certified EHR (not including payments from
state or local governments, in-kind contributions,
etc.)
The EP has reported the amount of cash
payments made directly attributable to him/her for
the certified EHR (not including payments from
state or local governments, in-kind contributions,
etc.)
The EP has confirmed That at least $3,750 of the
EHR technology is the responsibility of him/her or
his/her employer, group, clinic, hospital affiliation,
or in-kind contributions or grants
The EP has confirmed That at least $1,500 of the
EHR technology is the responsibility of him/her or
his/her employer, group, clinic, hospital affiliation,
or in-kind contributions or grants
The EP has confirmed assignment of his/her
payment to another TIN and agrees to this
assignment, if applicable
The EP has confirmed assignment of his/her
payment to another TIN and agrees to this
assignment, if applicable
The EPs percentage of SoonerCare encounters or
Needy Individual (for EPs practicing
predominantly in an FQHC/RHC) patient volume
is equal to or greater than the allowed percentage
of their specialty (See Appendix E)
The EP’s percentage of SoonerCare encounters
or Needy Individual (for EPs practicing
predominantly in an FQHC/RHC) patient volume
is equal to or greater than the allowed percentage
of their specialty (See Appendix E)
The EP has specified the patient volume date
range of at least 90 days
The EP has specified the patient volume date
range of at least 90 days
The EP has 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
State of Oklahoma
Oklahoma Health Care Authority
State Medicaid HIT Plan (SMHP)
CMS Letter 9/3/2010 Enclosure A
October 13, 2010 Page 13
During EHR Year 1 reporting period, the EP
attests:
During EHR Years 2 through 6 reporting
period, the EP attests:
The EP has satisfied the required objectives and
associated measures under §495.6(d) and
§495.6(e), except §495.6(d)(10) “Report
ambulatory clinical quality measures to the State”
The EP attests to meeting the MU criteria
associated with his/her year of participation and
applicable stage per the rule
If applicable, the EP attests that the clinical quality
measures not reported do not apply to any
patients treated by the EP
The EP attests that all information is true and
accurate per wording in the rule
The EP attests that all information is true and
accurate per wording in the rule
The EPs electronic signature on the attestation is
valid for the SoonerCare EHR Incentive Program
payment request
The EPs electronic signature on the attestation is
valid for the SoonerCare EHR Incentive Program
payment request
For all calendar years, an EP who practices in multiple physical locations, not all of which have
certified EHR technology available, the EP will demonstrate MU using only the locations where
the EP has certified EHR technology available.
In order to qualify for payment, the EP must meet the definition of §495.4 meaningful EHR user.
Hospitals enrolled in Medicare Incentive Payment Programs will be deemed eligible for
Medicaid – Oklahoma EHR Provider Incentive Payment Program. Payment will be made if
they have met all the eligibility criteria for Medicaid, and have met the Medicare definition
for MU.
Table 10 EHs and CAHs Attestations
Attestations apply to all hospitals unless otherwise noted.
EHs or CAHs eligible only for
the Oklahoma EHR Incentive
Payment Program, attesting to
Adopt, Implement, or Upgrade
in their first participation year
attests that:
During 2011 reporting period,
the EHs or CAHs attesting to
MU attests that:
During 2012 and subsequent
reporting periods, the EHs or
CAHs attesting to MU attests
that:
The EH or CAH adopted,
implemented or upgraded (A/I/U)
certified EHR technology
The EH or CAH used certified
EHR technology
The EH or CAH used certified
EHR technology
The EH or CAH has attested
using the most recent year
admissions with average
length of stay 25 days or less
to determine Medicaid patient
volume
The EH or CAH has attested
using the most recent year
admissions with average
length of stay 25 days or less
to determine Medicaid patient
volume
The EH or CAH has attested
using the most recent year
admissions with average
length of stay 25 days or less
to determine Medicaid patient
volume
The EHR product used is
certified and EH or CAH
The EHR product used is
certified and EH or CAH entered
State of Oklahoma
Oklahoma Health Care Authority
State Medicaid HIT Plan (SMHP)
CMS Letter 9/3/2010 Enclosure A
October 13, 2010 Page 14
EHs or CAHs eligible only for
the Oklahoma EHR Incentive
Payment Program, attesting to
Adopt, Implement, or Upgrade
in their first participation year
attests that:
During 2011 reporting period,
the EHs or CAHs attesting to
MU attests that:
During 2012 and subsequent
reporting periods, the EHs or
CAHs attesting to MU attests
that:
entered product certification
number, vendor, product, and
version
product certification number,
vendor, product, and version
The EH or CAH has reported the
number of FTE jobs created by
implementing this certified EHR
product
The EH or CAH has reported
the number of FTE jobs created
by implementing this certified
EHR product
The EH or CAH has reported the
number of FTE jobs created by
implementing this certified EHR
product
The EH or CAH satisfied the
required objectives and
associated measures under
§495.6(f) and §495.6(g).
The EH or CAH has satisfied the
required objectives and
associated measures under
§495.6(f) and §495.6(g), except
§495.6(f)(9) “Report hospital
clinical quality measures to the
State”
The EH or CAH attests that the
information submitted with
respect to clinical quality
measures was generated as
output from an identified certified
EHR technology
The EH or CAH attests that the
information was submitted to the
knowledge and belief of the
official submitting on behalf of
the EH or CAH
The EH or CAH attests that the
information submitted includes
information on all patients to
whom the measure applies (not
applicable to dually EHs)
For EHs or CAHs that do not
report one or more measures,
the EH or CAH attests that the
clinical quality measures not
reported do not apply to any
patients treated by the EH or
CAH during the reporting period
(not applicable to dually EHs)
The EH or CAH attests
numerators, denominators, and
exclusions for each clinical
quality measure result reported,
providing separate information
for each clinical quality measure
including the numerators,
State of Oklahoma
Oklahoma Health Care Authority
State Medicaid HIT Plan (SMHP)
CMS Letter 9/3/2010 Enclosure A
October 13, 2010 Page 15
EHs or CAHs eligible only for
the Oklahoma EHR Incentive
Payment Program, attesting to
Adopt, Implement, or Upgrade
in their first participation year
attests that:
During 2011 reporting period,
the EHs or CAHs attesting to
MU attests that:
During 2012 and subsequent
reporting periods, the EHs or
CAHs attesting to MU attests
that:
denominators, and exclusions
for all patients irrespective of
third-party payer or lack thereof;
for Medicaid patients. (not
applicable to dually EHs)
The EH or CAH attests the
beginning and end dates for
which the numerators,
denominators, and exclusions
apply (not applicable to dually
EHs)
The EH or CAH specified the
EHR reporting period and
provided the result of each
applicable measure for all
patients admitted to the
inpatient or emergency
department (Place Of Service
(POS) 21 or 23) of the hospital
during the EHR reporting period
for which a selected measure is
applicable
The EH or CAH specified the
EHR reporting period and
provided the result of each
applicable measure for all
patients admitted to the inpatient
or emergency department (POS
21 or 23) of the hospital during
the EHR reporting period for
which a selected measure is
applicable (not applicable to
dually EHs)
The EH or CAH attests that all
information is true and accurate
per wording in the rule
The EH or CAH attests that all
information is true and accurate
per wording in the rule
The EH or CAH attests that all
information is true and accurate
per wording in the rule
The EH or CAH electronic
signature on the attestation is
valid for the Oklahoma EHR
Provider Incentive Payment
Program payment request
The EH or CAH electronic
signature on the attestation is
valid for the Oklahoma EHR
Provider Incentive Payment
Program payment request
The EH or CAH electronic
signature on the attestation is
valid for the Oklahoma EHR
Provider Incentive Payment
Program payment request
Provider attestation information will be reviewed by OHCA to determine provider eligibility. The
EHR system certification number entered on the attestation has been verified prior to payment
being made. (OHCA is working with CMS and Office of National Coordinator (ONC) to automate
this process.) Providers determined to be eligible will receive incentive payment for that year.
Providers will have to re-attest each year to MU for each year’s participation in Oklahoma EHR
Provider Incentive Payment Program prior to receipt of an incentive payment.
OHCA will confirm the provider’s eligibility for the current year’s payment via the MMIS Provider
subsystem. OHCA will approve the provider incentive payment via the MMIS Financial sub-system.
State of Oklahoma
Oklahoma Health Care Authority
State Medicaid HIT Plan (SMHP)
CMS Letter 9/3/2010 Enclosure A
October 13, 2010 Page 16
The eligible EP and EH or CAH must maintain documentation supporting their demonstration of
MU for six years.
CMS Question 12: References to “when the CMS final rule is out” should be updated to reflect
that the final rule is now published and any associated policies should be adjusted to reflect the
final rule requirements.
Response: A search of the document was conducted to identify any references to “when the
CMS final rule is out.” One instance was found in Section 4.3.1.1 Recent Changes in State
Laws or Regulation. The sentence 2 in first paragraph was removed from the SMHP as shown.
Section 4.3.1.1 Recent Changes in State Laws or Regulation
MITA Reference: Develop and Maintain Program Policy (PG05)
A statewide regulatory review is underway; at this point, only minimal changes and no new
State laws are expected at this time. Once the Final Rule is released, it will be reviewed for any
changes to determine if the initial review is still relevant or if it needs revision.
CMS Question 13: Starting at page 85, please clarify how the State will calculate and/or ensure
this.
Response: Section 4.6.2.1 paragraph 1 has been amended as shown.
Section 4.6.2.1 EP Payment Calculations
OHCA will validate Provider “net” average allowable costs. EPs will attest to 1.) The amount
of cash payments directly attributable to only the EHR technology; and 2.) At least $3,750
(first year)/$1,500 (2nd – 6th years) have been paid by the EP or on their behalf by their
employer, in kind, grant, etc. OHCA will request supporting documentation on audit. The
amount of cash payments directly attributable to only EHR technology will be subtracted
from the Health and Human Services-defined Net Average Allowable Cost (NAAC) of
$54,000 (first year) or $20,610 (subsequent years), to arrive at the NAAC. If the NAAC
exceeds the maximum NAAC of $25,000 (first year) or $10,000 (subsequent years), the
NAAC will be reduced to the maximum NAAC allowed for that provider’s participation
year. The EHR incentive payment will be 85% of the maximum allowed NAAC, not to
exceed $21,250 in the first year and $8,500 in years 2-6. Pediatricians attesting to a
patient volume between 20% - 29% will receive 2/3 of the incentive payment amount.
Allowable costs for each provider must be adjusted in order to subtract any cash payment that is
made to SoonerCare EPs and is directly attributable to payment for certified EHR technology or
support services of such technology. Payments from State or local governments, in-kind
contributions and grants do not reduce the average allowable costs. The resulting figure is the
“net” average allowable cost, that is, average allowable cost minus payments from other
sources (other than State or local governments).
OHCA will calculate 85 percent of a “net” allowable cost not to exceed a maximum in the first
year of $21,250. Per §495.310, an EP may not begin receiving payments later than calendar
year 2016. For subsequent years, OHCA will calculate 85 percent of a NAAC, not to exceed a
maximum of $8,500. Payment after the first year may continue for a maximum of five years.
State of Oklahoma
Oklahoma Health Care Authority
State Medicaid HIT Plan (SMHP)
CMS Letter 9/3/2010 Enclosure A
October 13, 2010 Page 17
SoonerCare EPs may receive payments on a non-consecutive, annual basis. No payments may
be made after calendar year 2021. In no case shall a SoonerCare EP participate for longer than
six years or receive payment in excess of the maximum $63,750.
EPs that meet the State definition of Pediatrician and carry between 20 and 29 percent
Medicaid patient volume will have their payment reduced by one-third. The Pediatrician will not
receive more than $14,167 in the first year and not more than $5,667 for subsequent years. The
total allowable for six years will not exceed $42,500. All other requirements noted above for an
EP remain the same.
CMS Question 14: It appears that “SoonerCare” refers to both Medicaid and CHIP. Please add
clarifying language that the State understands that CHIP encounters do not count in the
calculation of Medicaid patient volume.
Response: Please see Section 4.5.1.4 above (see CMS Question 8); shown in entirety adds
paragraphs 1, 2, 3 and bullet #1.
CMS Question 15: Please clarify in the SMHP when discussing incentive payments or amounts
that these payments are not based upon a percentage of cost, and that they are incentives not
reimbursements.
Response: Section 4.3.1 text in sentence two has been amended as shown. Section 4.6.2.1
revisions are shown above in Question 13.
Section 4.3.1 Policy Changes
OHCA policy staff will conduct a comprehensive review of new policy required to implement the
SoonerCare Oklahoma EHR Provider Incentive Payment Program. At this time, OHCA
expects to create a new section of policy dedicated solely to the governance of these programs.
Within this new section, the agency will address administrative processes, provider eligibility
rules, and reimbursement incentive payment criteria and procedures. Specifically, OHCA will
address policy on issues related to SoonerCare patient volume standards, the definition of
pediatrician, MU criteria and payment to EPs. Where there is no specific written policy, OHCA
will defer to the Final Rule. issued by CMS. OHCA will also revise relevant sections of OHCA
Administrative Code (title 317), Chapter 2 Grievance rules to incorporate provider appeals
processes related to EHR incentive payments.
CMS Question 16: Starting on page 76, the SMHP indicates that the State may need to
conduct State rulemaking. Please clarify what rule-making will be needed, if rulemaking
presents any challenges to your January implementation, and provide any timelines for this
activity.
Response: Section 4.3.1.1 is shown in entirety. A new paragraph 2 is added in SMHP.
State of Oklahoma
Oklahoma Health Care Authority
State Medicaid HIT Plan (SMHP)
CMS Letter 9/3/2010 Enclosure A
October 13, 2010 Page 18
Section 4.3.1.1 Recent Changes to State Laws and Regulations
A statewide regulatory review is underway; at this point, only minimal changes and no new
State laws are expected at this time. Once the Final Rule is released, it will be reviewed for any
changes to determine if the initial review is still relevant or if it needs revision.
Rules have been developed and are going through the Oklahoma rule making process.
Areas addressed are: program description, eligible providers (under revision),
SoonerCare patient volume description by provider type (under revision), the
requirement of providers to maintain proof of encounters for out of state Medicaid
patients, A/I/U and MU definitions, the payment process and administrative appeals. The
timeline for implementation is contained within the simultaneously submitted IAPD and
are currently scheduled to be complete on or about December 1, 2010.
CMS Question 17: The SMHP indicates that “During the period of eligibility, be a SoonerCare
Contracted provider (exceptions may be providers who do not contract directly with OHCA but
are based in SoonerCare contracted FQHC, RHC, IHS, or Tribal facilities.” Please describe how
the State will pay EPs who want to use their own TIN as opposed to the clinic TIN.
Response: See Section 4.4. A new paragraph 2 is added to the SMHP as shown.
Section 4.4 OHCA Contract Changes
For purposes of the Oklahoma EHR Provider Incentive Payment Program, providers who
are based in contracted FQHC, RHC, IHS, or Tribal facilities will be required to complete a
rendering provider agreement. This agreement will require the provider to provide all
necessary information to receive an EHR Incentive payment and subsequent Internal
Revenue Service (IRS) Form 1099.
CMS Question 18: Starting on page 12, “A comprehensive review of new policy required to
implement the Oklahoma EHR Provider Incentive Payment Program will occur after the Final
Rule is released. OHCA anticipates a new section of policy dedicated solely to the governance
of the program. Based on the assessment, areas that must be addressed include policy related
to SoonerCare patient volume standards, the definition of pediatrician, MU criteria, and
payments to EPs. Where no specific written policy exists, OHCA will defer to the Final Rule
issued by CMS.” Please include specific information in the SMHP concerning all planned or
anticipated OHCA policy to implement the incentive program.
Response: See Section 1.1.3, paragraphs 4 and 5 have been amended as shown.
Section 1.1.3Provider Incentive Program Implementation
Another important ongoing activity is the review of regulatory requirements, identification of
policy and regulatory changes. OHCA policy staff will conduct a comprehensive review of new
policy required to implement the SoonerCare Oklahoma EHR Provider Incentive Payment
Program. At this time, OHCA expects to create a new section of policy dedicated solely
to the governance of the program. Within this new section, the agency will address
administrative processes, provider eligibility rules, and reimbursement incentive
payment criteria and procedures. Specifically, OHCA will address policy on issues
State of Oklahoma
Oklahoma Health Care Authority
State Medicaid HIT Plan (SMHP)
CMS Letter 9/3/2010 Enclosure A
October 13, 2010 Page 19
related to SoonerCare patient volume standards, the definition of pediatrician, MU
criteria, and payment to EPs. Where no specific written policy exists, OHCA will defer to
the Final Rule. OHCA will also revise relevant sections of OHCA Administrative Code
(title 317) Chapter 2 Grievance rules to incorporate provider appeals processes related to
EHR incentive payments.
The Oklahoma rules have yet to be finalized; however OHCA anticipates a final version
by late-October. Many of the areas are contingent upon CMS final acceptance of answers
in this update to the SMHP. However, areas identified in the rules are: program
description, eligible providers (under revision), SoonerCare patient volume description
by provider type (under revision), the requirement of providers to maintain proof of
encounters for out of state Medicaid patients, A/I/U and MU definitions, the payment
process and administrative appeals. Based on the timeline submitted with Oklahoma’s
IAPD, administrative rules for the program to include provider appeals are currently
scheduled to be complete on or about December 1, 2010.
CMS Question 19: The SMHP does not appear to discuss critical access hospitals in
Oklahoma. Please clarify if there are CAHs and how the State will address these providers in
the program, including OHCA outreach.
Response: See Section 2.5.2. A new paragraph 2 is added as shown.
2.5.2 Hospital and CAH Scan
The CAHs were included in the hospital survey. OHCA collaborated with the Oklahoma
Hospital Association to ensure CAHs were informed and aware of the Oklahoma EHR
Provider Incentive Payment Program opportunity. Information was made available to
CAHs on OHCA web site, numerous Oklahoma associations, upon request from
associations and through semi-annual provider training workshops.
CMS Question 20: Starting on page 74, Provider Eligibility. The State did not include
discussions of physician assistants practicing in FQHCs and RHCs. Please refer to the final
rule, and add this information to the SMHP.
Response: Section 4.4, a new paragraph 2 has been added to the SMHP. Section 4.5,
paragraphs 4 was amended and a new paragraph 5 added to the SMHP as shown.
Section 4.4 OHCA Contract Changes
For purposes of the Oklahoma EHR Provider Incentive Payment Program, providers who
are based in contracted FQHC, RHC, IHS, or Tribal facilities will be required to complete a
rendering provider agreement. This agreement will require the provider to provide all
necessary information to receive an EHR Incentive payment and subsequent IRS Form
1099.
Section 4.5 Provider Eligibility for Incentive Payments
At this time, providers and hospitals eligible for the SoonerCarePOklahoma EHR Provider
Incentive Payment Program are as follows:
State of Oklahoma
Oklahoma Health Care Authority
State Medicaid HIT Plan (SMHP)
CMS Letter 9/3/2010 Enclosure A
October 13, 2010 Page 20
  Physicians
  Pediatrician
  Nurse Practitioner
  Certified Nurse Midwife
  Physician Assistants practicing in FQHCs and RHCs led by a Physician Assistant
  Dentist
  Acute Care hospital
  Children’s Hospital
A FQHC or RHC is considered to be PA led when: 1.) the PA is the primary provider in a
clinic (e.g., part time physician and full time PA in the clinic); 2.) the PA is the clinical or
medical director at a clinical site of the practice; or 3.) the PA is the owner of the RHC.
CMS Question 21: Starting on page 75, (§4.5.1.8), ensure providers are licensed, not
sanctioned. CMS would like additional detail about how the State enrolls providers into their
SoonerCare program and how OHCA will ensure that they are protecting the Oklahoma EHR
Provider Incentive Payment Program from excluded, sanctioned or debarred providers.
Response: See Section 4.5.1.8. A new paragraph 2 is added and a new second sentence is
added to paragraph 3 as shown.
Section 4.5.1.8 Ensure Providers are Licensed; Not Sanctioned
MITA Reference: Enroll Provider (PM 01) and Disenroll Provider (PM 02)
OHCA’s existing process for checking provider licensure and sanctioning will be employed for
the Oklahoma EHR Provider Incentive Payment Program as well.
SoonerCare contracts are generated using an online web application called EPE. The
application is filled out by a provider, electronically signed and electronically enrolls
provider once necessary licensure and credentialing documentation has been faxed to
OHCA and proper verification has been performed.
All providers are manually checked for sanctions before being enrolled in SoonerCare. Once a
month, CMS sends a file that is run against the provider file to check for any new sanctions. The
monthly sanction listing is continuously used to verify eligibility of currently contracted
providers as well as providers seeking to enroll as a SoonerCare provider. CMS also
sends letters when new providers to the State are sanctioned. OHCA staff use multiple local
resources to identify new sanctions. All these sources will be reviewed prior to completing any
provider’s enrollment in the Oklahoma EHR Provider Incentive Payment Program.
While I/T/U providers are required to be licensed, they are not required to have a valid
Oklahoma license. As part of the EPE contracting process, OHCA verifies with the appropriate
State licensing entity that the I/T/U provider has a valid license.
CMS Question 22: Starting on page 91 (§4.9.2), Fraud and Abuse Prevention. “OHCA plans
additional annual audit activities to support the validation of provider attestations and provider
data submissions to ensure compliance with the federal program. “Please clarify how the State
State of Oklahoma
Oklahoma Health Care Authority
State Medicaid HIT Plan (SMHP)
CMS Letter 9/3/2010 Enclosure A
October 13, 2010 Page 21
will conduct these audits, and whether the State plans to utilize contractors for this purpose”.
Please describe any scope of work that is anticipated for contractors.
Response: See Section 4.9.2, paragraphs 4 through 8 are added as shown.
Section 4.9.2 Fraud and Abuse Prevention
OHCAs Program Integrity and Accountability Unit will conduct annual audits of provider
incentive payments. There is no plan to use contractors to perform any audits of this
program. Audits will be conducted via statistical sampling. Volume, scope, methods, and
procedures will be based on risk assessments and materiality consistent with the OHCA
Program Integrity and Planning Division Audit Review Process. Guidance in the Audit
Review Process handbook outlines the steps below to define Audit Scope.
Assessment and Analysis
The audit assessment and analysis phase includes steps necessary to assemble
information that will enable the audit team to make decisions concerning the nature,
timing, and extent of detailed audit work. The review includes a timely gathering and
analysis of information so that potential audit areas can be identified and plans made to
review and test management controls over these areas.
Focus Objectives
Focusing on objectives is a function of the internal control assessment and risk analysis,
which can be done systematically through the process of a survey.
Risk Analysis and Internal Control Assessment
The purpose of the audit survey is to identify areas of potential audit risk and design
audit work to minimize the risk. The audit team should target its resources in areas with
the most risk. This requires that the audit team gain an understanding of the internal
control structure. With this understanding, the team should identify the controls that are
relevant to the objectives of the audit. The team should then assess the relative control
risk for each control. There are several approaches to making a risk analysis and internal
control assessment. Regardless of the method followed, the team must consider all
factors relevant to the audit objective. These factors include materiality, significance of
legal and regulatory requirements, and the visibility and nature of the government
programs.
Refine Objectives
Through a careful process of analyzing risk and assessing internal controls, the team
must ensure that the audit objectives cover the areas of highest risk consistent with
resource limitations. The team should refine the overall objective(s) established in the
preliminary planning phase when necessary.
CMS Question 23: Starting on page 91 (§4.9.3). Provider Appeals. Please clarify when the
State anticipates having administrative rules in place that allow for provider appeals, and any
obstacles to implementation, such as rules processing time, provider notice, etc.
State of Oklahoma
Oklahoma Health Care Authority
State Medicaid HIT Plan (SMHP)
CMS Letter 9/3/2010 Enclosure A
October 13, 2010 Page 22
Response: See Section 4.9.3, paragraph 1 is amended as shown.
Section 4.9.3 Provider Appeals
OHCA will have a process in place for a provider to appeal incentive payments, provider
eligibility determination, and efforts to adopt MU in the Oklahoma EHR Provider Incentive
Payment Program. Based on the timeline submitted with Oklahoma’s IAPD, administrative
rules for the program to include provider appeals are currently scheduled to be complete
on or about December 1, 2010.