EHR incentive program appeals flow through agency portal


The Centers for Medicare & Medicaid Services has released specifics about how physicians and hospitals may appeal decisions that prevent them from receiving or keeping payment as part of the EHR Incentive Program.

The agency has added to its attestation Web site new information about the appeals process for the incentive program to adopt electronic health records.

The agency’s Office of Clinical Standards and Quality (OCSQ) provides guidance on how to file an appeal.

CMS began accepting appeals in December 2011 for eligible physicians and professionals, hospitals and critical access hospitals. OCSQ released the first informal review decision for the EHR Incentive Program on Jan. 19.

OCSQ has contracted with Provider Resources Inc. (PRI), of Erie, Pa., to supply customer support and technical assistance for incentive program appeals. Providers must use PRI’s portal to file appeals, reconsideration requests, and supporting documentation. Providers can also check the status of appeals through the portal, CMS said.

Starting in March, providers may find the decisions to their appeals at the portal.

The filing deadline for an eligibility appeal for hospitals has been extended a month to Jan. 30 for the 2011 EHR reporting period. Since physicians have until Feb. 29 to register and attest for incentives considered part of the 2011 reporting period, their filing deadline is later.

Providers may appeal based on eligibility, meaningful use and incentive payment calculation, and will have the opportunity to request a reconsideration of appeal after an informal review finding. Appeals are based on:

  • Eligibility: Provider shows that all the EHR Incentive Program requirements were met and should have received payment but could not because of circumstances outside of the provider’s control 

  • Meaningful use: Provider demonstrates use of certified EHR and meeting required objectives and associated measures after a successful attestation 

  • Incentive payment calculation: Provider verifies inclusion of Medicare claims data that was not used in determining the amount of the incentive payment.

For the informal review decision, PRI will gather evidence from various sources to evaluate and verify the provider’s information in the appeal filing. Providers may have to supply more documentation. Providers may request reconsideration if they take issue with the decision. Otherwise, the informal review decision stands.

CMS will review a request for reconsideration and make a final decision within 10 days.

In 2011, according to CMS, 33,595 Medicare physicians and professionals and 842 acute care and critical access hospitals had attested to meeting meaningful use requirements. Of the physicians, 355 were unsuccessful, while all hospitals passed.

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