10 Colo. Code Regs. § 2505-10-8.015
Current through Register Vol. 47, No. 16, August 25, 2024
Section 10 CCR 2505-10-8.015 - ELECTRONIC HEALTH RECORD INCENTIVE PAYMENT PROGRAM8.015.1INCORPORATION BY REFERENCETitle 42 of the Code of Federal Regulations, Part 495 (2010) is hereby incorporated by reference into this rule. Such incorporation, however, excludes later amendments to or editions of the referenced material. These regulations are available for public inspection at the Department of Health Care Policy and Financing, 1570 Grant Street, Denver, CO 80203
8.015.2DEFINITIONSPediatrician means a medical doctor who holds a board certification in Pediatrics from the American Board of Pediatrics or provides greater than 50% of services to patients who are 18 years of age or younger.
8.015.3ELIGIBLE PROVIDERS8.015.3.A. To qualify for incentive payments, a provider must be an eligible professional or eligible hospital as specified in 42 CFR § 495.4 and 42 CFR § 495.304, and must have an active Colorado Medicaid provider identification number that has been assigned and is maintained by the Department.8.015.3.B. An eligible professional participating in the Medicare electronic health record incentive program is not eligible to receive the Medicaid incentive payment through the Colorado Medicaid Electronic Health Record Incentive Payment Program in the same participation year.8.015.4ACTIVITIES REQUIRED TO RECEIVE THE INCENTIVE PAYMENT8.015.4.A. Eligible professionals and eligible hospitals must register with the Department in order to be eligible to participate in the incentive program.8.015.4.B. An eligible professional or eligible hospital in the first participation year under the Colorado Electronic Health Record Incentive Payment Program must attest to adopting, implementing or upgrading electronic health record technology that has been certified by the Office of the National Coordinator for Health Information Technology, as defined in 42 CFR § 495.302, in order to be eligible to receive payment for the first year of participation. 8.015.4.C. Eligible professionals in their second through sixth participation years and eligible hospitals in their second and third participation years must attest to meaningful use of certified Electronic Health Record technology for each year of participation in order to be eligible to receive payment for that year. 1. For eligible professionals, attestation to meaningful use means that the eligible professional meets the meaningful use criteria set forth in 42 CFR § 495.6(a), (c) and (d).2. For eligible hospitals, attestation to meaningful use means that the eligible hospital meets the meaningful use criteria set forth in 42 CFR § 495.6(b), (c) and (e).8.015.4.D. Eligible professionals and eligible hospitals must submit all statements of attestation and retain documentation to support attestations.8.015.5ESTABLISHING MEDICAID PATIENT VOLUME8.015.5.A. Eligible professionals and eligible hospitals must establish and demonstrate the Medicaid patient volume necessary for participation in the Colorado Medicaid Electronic Health Record Incentive Payment Program, using the patient volume methodologies defined in 42 CFR § 495.306(c) or (d). Eligible professionals and eligible hospitals must attest to meeting Medicaid patient volume requirements and demonstrate evidence of attested patient volume upon the request of the Department.8.015.6INCENTIVE PAYMENTS8.015.6.A. Payments to eligible professionals are calculated in the manner defined in 42 CFR § 495.310 once for each year of eligibility after the eligible professional has submitted the required attestation. Payments are disbursed one time per year of eligibility. 8.015.6.B Payments to eligible hospitals are calculated one time only, when the eligible hospital registers to participate in the Incentive Program and makes the appropriate attestation. Payments are calculated in the manner defined in 42 CFR § 495.310. These payments are disbursed one time per year of eligibility over a three-year period.8.015.7SUSPENSION, EXCLUSION AND OFFSET OF PAYMENTS8.015.7.A The Department may suspend payment of incentive payments to an eligible provider under any of the following conditions:1. The provider fails to timely and completely comply with the audit obligations contained in the Audit section of these rules;2. The provider is under an active audit at the time of payment;3. The provider has a deficiency finding resulting from an audit or review and is required, at the time of payment, by the Department or duly authorized agent of the Department, to initiate or to complete a Corrective Action Plan;4. There is a credible allegation that the provider has falsified documents or made false or misleading attestations;5. There is a credible allegation of fraud related to the provider's participation in the medical assistance program;6. There is a credible allegation that the provider has retaliated against an employee for whistle blowing about a provider's non-compliance with program requirements or about a provider's false attestations;7. The provider is on the federal Office of Inspector General exclusion list at the time of payment;8. The provider is indicted for, or found guilty of, an action in any state or federal court that could qualify for exclusion on the federal Office of Inspector General exclusion list;9. The provider has been served and is subject to any civil or false claims action seeking the return of medical assistance benefits or another incentive payment;10. The provider's medical assistance benefits are suspended;11. The provider owes the Department a refund of medical assistance benefits, or is subject to offset or collection activities;12. The federal government requests a suspension;13. The provider has been terminated for cause from Colorado's medical assistance program, the medical assistance program of another State, or from Medicare; or14. The Department determines that suspension is in the best interests of the public.8.015.7.B. An eligible provider may be excluded from participation in the program under any of the following conditions:1. The provider repeatedly fails to comply with the audit obligations contained in the Audits section of these rules;2. There a judicial finding that the provider has falsified documents or made false or misleading attestations;3. The provider is listed on the federal Office of Inspector General exclusion list;4. The federal government requests exclusion;5. The provider has failed to satisfactorily or timely complete a Corrective Action Plan; or6. The provider has been terminated for cause from participation in Colorado's medical assistance program, the medical assistance program of another State, or from participation in Medicare.8.015.7.C. The Department may recoup by offset any incentive payments that did not meet program requirements from other incentive payments due to the eligible provider, from medical services benefits payments due to the eligible provider or from medical services benefits due to another Medicaid provider who is billing for the eligible provider's services.8.015.7.D. The Department may recoup by offset any improper or overpaid medical services benefits paid to or on behalf of an eligible provider from any incentive payment to that eligible provider under this program.8.015.8AUDITS8.015.8.A. Eligible providers shall maintain all program-related records including documentation to support attestations and use and expenditures for seven years for audit purposes8.015.8.B. Eligible providers shall permit the Department, the federal government, the Medicaid Fraud Control Unit and any other duly authorized agent of a governmental agency: 1. To audit, inspect, examine, excerpt, copy and/or transcribe the records related to this incentive program, to assure compliance with the program requirements, Corrective Action Plans and attestations.2. To access the provider's premises, to inspect and monitor, at all reasonable times, the provider's compliance with program requirements, Corrective Action Plans and attestations. Monitoring includes, but is not limited to, internal evaluation procedures, examination of program data, special analyses, on-site checking, observation of employee procedures and use of electronic health information systems, formal audit examinations, or any other procedure.8.015.8.C. Eligible providers shall cooperate with the State, the federal government, the Medicaid Fraud Control Unit and any other duly authorized agent of a governmental agency seeking to audit a provider's compliance with program requirements, Corrective Action Plans and attestations. Upon request, and at the provider's expense, providers shall make available all necessary and complete records for audit purposes and shall deliver copies of purchase receipts and other documentation to the Department or any other duly authorized agent as specified in the request. 8.015.8.D. Upon request, eligible providers shall demonstrate to the State, the federal government, the Medicaid Fraud Control Unit and any other duly authorized agent of a governmental agency, that the provider can perform those actions and activities: 1. to which the provider has attested, or2. which are required by a Corrective Action Plan.8.015.9CORRECTIVE ACTION PLANS8.015.9.A. An eligible provider who fails to conform to program requirements or for whom deficiencies have been identified may be required to initiate and complete a Corrective Action Plan, as approved by the Department or its duly authorized agent. The purpose of the Corrective Action Plan is to assure that the eligible provider comes into conformity with program requirements and corrects deficiencies, at the provider's sole expense.8.015.9.B. The Corrective Action Plan shall be provided to the auditor at the completion of the audit or within two weeks of a when requested by the Department or its duly authorized agent, unless an extension is granted. The plan shall identify: 1. The actions or corrective measures that the Provider will take to correct the identified deficiencies, to bring the providers operations into compliance with program requirements, or will take to achieve recommended improvements; 2 The name of the contact person responsible for corrective action; and3. The anticipated completion date.8.015.10APPEALS8.015.10.A. A provider may request informal reconsideration of any of the following Electronic Health Records Incentive Payment Program decisions that the provider disputes: 1. Eligibility determinations. A provider excluded from participation in the program may challenge that denial by mailing, or hand delivering, to the Department a written request for an informal reconsideration of the denial within 30 days of its issuance. A copy of the denial, if written, must be enclosed with the request.2. Incentive payments, including payment amounts.a. An eligible provider dissatisfied with a decision to deny the eligible provider all or part of an incentive payment, or dissatisfied with the amount of an incentive payment, may challenge that decision by mailing, or hand delivering, to the Department a written request for informal reconsideration of the decision within 30 days of the issue date of the decision. A copy of the decision must be enclosed with the request for informal reconsideration with an explanation of the basis for the appeal.b. An eligible provider dissatisfied with a decision to suspend payment of an incentive payment or to an offset of incentive payments, may challenge those actions by mailing, or hand delivering, to the Department a written request to review the action taken within 30 days of the action.3. Demonstration of adopting, implementing, and upgrading technology, or demonstration of meaningful use. An eligible provider dissatisfied with findings regarding attestations for adopting, implementing or upgrading technology, or meaningful use of technology, may appeal the audit by mailing, or hand delivering, to the Department a written request to review the audit results within 30 days of the action.4. Audit results. An eligible provider dissatisfied with the results of an audit may appeal the audit by mailing, or hand delivering, to the Department a written request to review the audit results within 30 days of the action.5. Corrective action plan. An eligible provider dissatisfied with issues related to a Corrective Action Plan, may appeal by mailing, or hand delivering, to the Department a written request to review the Corrective Action Plan within 30 days of the action.8.015.10.B. A provider dissatisfied with the Department's informal reconsideration decision may submit a written appeal of the decision by mailing, or hand delivering, to the Department a written request to review the informal reconsideration decision within 30 days of the date of the decision. This result of this review is the final agency decision.8.015.10.C. All written requests for informal reconsideration or appeal of the informal reconsideration decision must be mailed to: Department of Health Care Policy and Financing, ATTN: Internal Audit Section, 1570 Grant St, Denver, CO 80203.
8.015.10.D. A provider dissatisfied with a Department's final agency decision may appeal that decision according to the procedures set forth in 10 CCR 2505-10 Section 8.050, 3, PROVIDER APPEALS.