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Louisiana Medicaid EHR Incentive Payment Program Application and Attestation Form To complete this form you will need to complete the following worksheets (available for download at http://www.lamedicaid.com/provweb1/EHR/EHRIndex.htm): a. Patient Volume worksheet ‐ Eligible Professionals (EPs) and Eligible Hospitals (EHs) b. Hospital calculations worksheet ‐ Eligible Hospitals (EHs) only SECTION I – LOUISIANA MEDICAID PROVIDER INFORMATION: Provider ID: _____________________________________________________ Provider Name: _____________________________________________________ NPI: _____________________________________________________ Provide a primary and secondary point of contact for email correspondence related to the EHR Incentive Program application and attestation process. Primary Contact: Name: _____________________________________________________ Phone Number: _____________________________________________________ Email: _____________________________________________________ Job Title: _____________________________________________________ Secondary Contact: Name: _____________________________________________________ Phone Number: _____________________________________________________ Email: _____________________________________________________ Job Title: _____________________________________________________ 1 | P a g e Louisiana Medicaid EHR Incentive Program SECTION II – REQUIRED OF ELIGIBLE PROFESSIONALS (EPs) Answer yes or no to the following questions: 1. Do you provide more than 90% of your services in an inpatient hospital or ER?  Yes  No Hospital-Based means a professional furnishes ninety percent (90%) or more of their
Louisiana Medicaid-covered professional services during the relevant EHR reporting
period in a hospital setting, whether inpatient or Emergency Room, through the use of the
facilities and equipment of the hospital; verified by MMIS claims analysis. 2. Do you practice predominantly in an FQHC or RHC where 30% of the patient volume is derived from needy individuals?  Yes  No Practices predominantly - an EP for whom more than fifty percent (50%) of his or her
total patient encounters occur at a federally qualified health center (FQHC) or rural health
clinic (RHC). The calculation is based on a period of six (6) months in the most recent
calendar year. 3. Are you a Physician Assistant who practices in an FQHC or RHC so led by a Physician Assistant (PA)?  Yes  No led by a Physician
So
Assistant:
 A PA is the primary provider in a clinic (for example, when there is a part-time
physician and full-time PA, we would consider the PA as the primary provider);
 A PA is a clinical or medical director at a clinical site of practice; or
 A PA is an owner of an RHC.
2 | P a g e Louisiana Medicaid EHR Incentive Program SECTION III – REQUIRED OF ELIGIBLE PROFESSIONALS (EPs) AND ELIGIBLE HOSPITALS (EHs) Please provide the following information regarding your ‘certified’ EHR system: 1. EHR Vendor: ____________________________________________ 2. EHR License Number: ____________________________________________ 3. EHR License Expiration Date: ____________________________________________ 4. EHR Version Number: ____________________________________________ 5. EHR Date Last Updated: ____________________________________________ 6. NLR Certified EHR Code: ____________________________________________ SECTION IV – REQUIRED OF ELIGIBLE HOSPITALS (EHs) Eligible Hospitals must complete the EH incentive payment worksheet prior to completing this section. 1. Overall EHR amount from Step 4 of the worksheet: $_____________________ 2. Medicaid share from Step 5 of the worksheet: 0.00%
$_____________________ SECTION V – REQUIRED OF ELIGIBLE PROFESSIONALS (EPs) AND ELIGIBLE HOSPITALS (EHs) Eligible Professionals and Eligible Hospitals must provide the following information regarding your patient volume from the EP and EH Patient Volume Worksheet. You must indicate the 90 day period within the previous year from which your totals were obtained. 1.
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Begin date of 90 day period (mm/dd/yyyy): _________________________ End date of 90 day period (mm/dd/yyyy): _________________________ Total Medicaid/Needy Encounters: _________________________ Total Patient Encounters: _________________________ 3 | P a g e Louisiana Medicaid EHR Incentive Program SECTION VI – ATTESTATION ‐ ELIGIBLE PROFESSIONALS (EPs) AND ELIGIBLE HOSPITALS (EHs) This attestation serves to certify that the foregoing information is true, accurate, and complete. I understand that Medicaid EHR incentive payments submitted under this provider number will
be from Federal funds, and that any falsification or concealment of material fact may be prosecuted under Federal and State laws. DHH may ask for additional information on any of the information submitted as part of this form. DHH will pursue repayment in all instances of improper or duplicate payment. Preparer Signature: ________________________________________ Preparer Name (printed) ________________________________________ Prepared on behalf of: EP or EH name: ________________________________________ Medicaid Provider Id: ________________________________________ DIRECTIONS Print and sign this completed form. Scan a copy of the signed form. Submit this form along with other required documentation detailed below via email to ehrincentives@la.gov. In the subject line, please type EHR Incentives/(EP or EH name) *Required documentation: Eligible Professionals (EPs)  A completed and signed Application and Attestation Form  A completed Patient Volume Worksheet  Documentation regarding the EHR software adopted (contract, sales receipt, invoice) Eligible Hospitals (EHs) 
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A completed and signed Application and Attestation Form A completed Patient Volume Worksheet A completed Hospital Calculations Worksheet Supporting annual cost reports used during completion of Hospital Calculations Worksheet Documentation regarding the EHR software adopted (contract, sales receipt, invoice) 4 | P a g e Louisiana Medicaid EHR Incentive Program