This toolkit provides definitions, info sheets, and user guides for Meaningful Use and the Medicaid EHR Incentive Program for Eligible Professionals (EP). Notes: Read the CQM Reporting Period warnings in the CQM section of the MU tab. The Program Year 2020 attestation period has been extended until Mar 2, 2021.









Overview of New Requirements
This page of the MU Toolkit highlights recent updates to the Medicaid EHR Incentive Program for Program Years 2020 and 2019.
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What an EP needs to know for Program Year 2020
- PY2020 has a shortened timeline. To read the new PY2020 - PY2021 Timelines Guide, click here.
- Attest for PY2020 in MAPIR between Oct 1, 2020 and Mar 2, 2021.
- The MU reporting period will be any continuous 90-day period from Jan 1, 2020 through Dec 31, 2020.
- Providers are required to attest to Meaningful Use Stage 3.
- To review the PY2020 API Attestation Guide, click here.
- The CQM Reporting Period is any 90 days for all providers.
- Any EP who was previously approved for payment can continue in the program.
- EPs who have switched employer and have not yet received 6 incentive payments can attest as well.
- EPs are recommended to use the PVT Calculator to determine their PVT. To learn more click here.
- Use the information presented in the Program, Registration, Attestation, and other tabs to apply for incentives.
What an EP needs to know for Program Year 2019
Starting with Program Year 2019, participating EPs must attest to MU Stage 3, and they must upgrade to a 2015 Edition CEHRT.
The 2015 Edition must be installed and used for the entirety of the selected 90-day EHR reporting period. Don’t wait. The sooner your EPs upgrade to a 2015 Edition CEHRT, the more flexibility you will have in selecting the most suitable 90-day EHR Reporting Period.
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CMS made a concession for the API requirements. To learn more click here.
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MAPIR is now open for PY2019 attestations.
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EPs are recommended to use the PVT Calculator to determine their PVT. To learn more click here.
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Stage 3 has only 8 objectives that further consolidate the objectives and measures of Modified Stage 2.
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An EP also needs to meet the requirements for the Clinical Quality Measures (CQMs).
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Note: Read the PY2019 CQM Reporting Period warning in the CQM section of the MU tab of this toolkit.
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To accommodate COVID-19 priorities, the MU attestation deadline has been extended to Monday, Aug 31, 2020.
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The MU reporting period will be any continuous 90-day period from Jan 1, 2019 through Dec 31, 2019.
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EPs can no longer initiate first-time participation in the program and AIU attestation is no longer available.
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However, any EP who previously attested and was approved for payment can continue in the program.
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This includes EPs who have switched employer and have not yet received 6 incentive payments.
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Use the information presented in the Program, Registration, Attestation, and other tabs to apply for incentives.
Promoting Interoperability (PI) Programs
In 2018, CMS renamed the EHR Incentive Programs to the Promoting Interoperability (PI) Programs, which covers both the HITECH and MACRA programs. As such, the Medicaid EHR Incentive Program is now part of the PI Programs.
CMS now officially refers to the Medicaid EHR Incentive Program as the Medicaid Promoting Interoperability Program. Please note that Massachusetts has not updated the program's name, but may do so in the future.
Medicaid EHR Incentive Program
Eligible Professionals (EPs) have been able to earn incentives from the Medicaid EHR Incentive Program to Adopt, Implement, or Upgrade (AIU) to Certified EHR Technology (CEHRT) and demonstrate Meaningful Use (MU):
The Program Year 2020 attestation period has been extended until Mar 2, 2021. In 2018, CMS renamed the EHR Incentive Programs to the Promoting Interoperability (PI) Programs, which covers both the HITECH and MACRA programs. As such, the Medicaid EHR Incentive Program is now part of the PI Programs. CMS now officially refers to the Medicaid EHR Incentive Program as the Medicaid Promoting Interoperability Program. Please note that Massachusetts has not updated the program's name, but may do so in the future. |
Medicaid EHR Incentive Program Registration
To participate in the EHR Incentive Program, EPs must be recognized in MMIS, MassHealth's Medicaid Management Information System. EPs are required to register through the CMS Registration and Attestation System (R&A). The data entered (name, address, NPI,...) will be matched against MMIS. To successfully register with CMS, EPs must have:
- National Provider Identifier (NPI)
- Identify and Access (I&A) Id and Password
- Payee Tax Identification Number (TIN)
- EHR Certification Number
As of Program Year 2017, EPs can no longer use the CMS R&A system to initiate first-time participation in the Medicaid EHR Incentive Program. However, existing Meaningful Use participants can access the R&A system to make changes to an EP's registration to update the information, e.g. after a switch to a different organization.
Note: EPs can register and attest themselves and/or can authorize a designee to act on their behalf. A successful registration results in a “Welcome to MAPIR” email notification with instructions on how to access MAPIR to begin the attestation process.
Step 1: Assign a Designee (Optional for EPs) |
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I&A Instructions |
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Identity & Access Quick Reference Guide to assign designee to attest on behalf of EP |
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Step 2: Register in the CMS R&A System |
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Registration Instructions |
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CMS Registration & Attestation (CMS R&A) User Guide for EPs |
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Step 3: Special Enrollment (Upon Request only, for EPs not recognized or inactive in MMIS ) |
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Checklist and Forms |
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Special Enrollment Checklist for EPs |
Medicaid EHR Incentive Program Attestation
Annual attestation must be completed by the designee assigned to attest on behalf of the EP. To attest, use MAPIR, the state's attestation system, which is accessible via the Provider Online Service Center on the MassHealth website. Log into MAPIR using the Virtual Gateway username and password provided during registration. MAPIR will guide you in entering the data required to demonstrate an EP meets the program requirements, and a link to the MAPIR User Guide is included below.
The EP or appointed designee must upload supporting documentation to the EP’s MAPIR application prior to submittal for review. Please reference the Supporting Documentation Guides below.
Supporting Documentation Requirements |
Adopt, Implement, or Upgrade (AIU) to CEHRT
As of Program Year 2017, EPs can only earn incentives for Meaningful Use (MU). EPs can no longer earn incentives for Adopting, Implementing or Upgrading (AIU) to Certified EHR Technology (CEHRT). The information below is provided for participants who have an outstanding AIU application, for a prior Program Year, that has not yet been approved for payment.
Up to Program Year 2016, first year participants needed to attest that they met the program's eligibility criteria, and demonstrate they had Adopted, Implemented, or Upgraded (AIU) to CEHRT. As of 2014, participants also had the option to immediately attest to Meaningful Use in the first year, skipping AIU attestation. To qualify for AIU, EPs had to either:
• Adopt: Acquire, purchase or secure access to CEHRT
• Implement: Install or initiate the use of CEHRT
• Upgrade: Expand existing EHR functionality to CEHRT
AIU Resources |
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MeHI EHR Toolkit |
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EHR Planning and Procurement Toolkit |
Attesting to Meaningful Use
Starting with Program Year 2019, all participating EPs need to attest to Stage 3. Stage 3 has only 8 objectives that further consolidate the objectives and measures of Modified Stage 2. An EP also needs to meet the Clinical Quality Measures (CQMs) requirements.
EPs can no longer initiate first-time participation in the program, but any EP who previously attested, was approved for payment, and has not yet received 6 incentives, can continue to attest for Meaningful Use.
Stage 3 requires a 2015 Edition CEHRT.
The EP or appointed designee must upload supporting documentation to the EP’s MAPIR application prior to submittal for review. Please reference the Supporting Documentation Guides below.
Modified Stage 2 and Stage 3 Overviews |
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Documentation Guide Documentation Guide MU MeHI Presentations |
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2020 Supporting Documentation Guide for EPs - Version 8/12/2020 2019 Supporting Documentation Guide for EPs - Version 11/22/2019 (API Concession Scenarios Added) Modified Stage 2 Meaningful Use Presentations for Each Objective |
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MU - Clinical Quality Measures (CQMs)PY2020 Warning: All EPs must report a 90 day CQM Reporting Period!!! PY2019 Warning: EPs who have previously attested to MU must report a 365 day CQM Reporting Period!!! EPs who attest to MU for the first time, must use a 90 day CQM Reporting Period. Note: Massachusetts does not accept eCQM submissions. To participate in the Medicaid EHR
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CMS Website Page |
2018 eCQM Library |
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MU - Privacy & Security |
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MU Info Sheet |
Privacy and Security Guide |
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MU - Health Information Exchange |
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CMS Tip Sheet |
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Health Information Exchange "Last update Mar 2016" |
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MU - Patient Engagement |
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CMS Tip Sheet |
Patient Electronic Access "Last update Mar 2016" |
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MU - Medication Reconciliation |
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ONC Toolkit |
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MU - Prior Program Year Resources |
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Documentation Guide |
2018 Supporting Documentation Guide for EPs - Version 2/25/2019 (Clarifications added) |
Public Health Measures Reporting
MU Modified Stage 2 and Stage 3 require EPs to attest to the Public Health Reporting objective, which requires using Certified EHR Technology (CEHRT) to submit data to public health and/or specialized registries.
The Public Health Reporting objective requires active engagement with two or more of the following:
Stage 3 future program years: 5. Clinical Data Registry Watch this video, read the details below, or visit this website to learn how the Massachusetts Department of Public Health (MDPH) assists EPs in meeting the objectives. |
Immunization Registry (Measure 1)
MIIS, the Massachusetts Immunization Information System, is a web-based registry that collects patient immunization data. MIIS accepts electronic immunization messages (VXU) from CEHRT systems in the HL7 2.5.1 format. This satisfies Meaningful Use purposes. Technical specifications can be found on the MIIS Providers webpage.
Note that pursuant to M.G.L. Chapter 111, Section 24M, all licensed health care providers who administer immunizations are required to report immunization data to MIIS. EPs can claim an exclusion for the MU measure if they do not administer immunizations to any of the populations for which data is collected during the EHR reporting period.
For more information, and to register intent to submit immunization data, contact the MIIS Help Desk at 617-983-4335 or miishelpdesk@state.ma.us.
The MDPH also holds weekly MIIS Technical Support calls:
When: Every Thursday from 10:BAM to 11:00 AM EST
Phone: (605) 562-3000. Enter Access Code: 580574#
Syndromic Surveillance (Measure 2)
MDPH accepts syndromic surveillance data from EPs who practice in a freestanding urgent care facility. All other EPs can claim an exclusion for this measure. Save or print a screenshot of the MDPH Meaningful Use and Public Health Reporting webpage to document the reason for claiming the exclusion.
Electronic Case Reporting (Stage 3 Measure 3)
Electronic Case Reporting is a new Stage 3 requirement. It was not yet required nor available for Program Year 2018. It is required, and may become available in Massachusetts, for Program Year 2019.
Specialized Registry / Public Health Registry (Modified Stage 2 Measure 3 / Stage 3 Measure 4)
Specialized Registry Reporting is a Modified Stage 2 measure. In Stage 3, this measure is renamed to Public Health Reporting, but the requirements stay the same.
EPs who do not collect data relevant to a Specialized / Public Health Registry within their "jurisdiction" may claim an exclusion for this measure, since there is no registry available relevant to their scope of practice. However, the definition of “jurisdiction” is dependent on the type of registry, and the scope of "jurisdiction" may be local, state, regional or national.
EPs may be able to meet the Specialized / Public Health Registry measure by reporting to a national clinical data registry:
- Some national professional associations, such as the American College of Cardiology, American Academy of Ophthalmology, and American College of Rheumatology have made clinical data registries available to their members.
The Commonwealth of Massachusetts offers two options for Specialized / Public Health Registry Reporting:
- The Massachusetts Cancer Registry (MCR) supports electronic reporting from CEHRT systems. If you are an EP who treats cancer patients and are interested in reporting to the MCR, contact Susan T. Gershman at susan.gershman@state.ma.us.
- The Bureau of Infectious Disease Prevention at the MDPH has implemented electronic infectious disease case reporting into a specialized registry, the Massachusetts Virtual Epidemiologic Network (MAVEN). The registry accepts electronic medical case reports for acute hepatitis, active tuberculosis, and sexually-transmitted diseases. As onboarding participants is resource intensive, MDPH limits participation via a threshold based on incidence of reportable conditions seen by providers over a 12-month period. For EPs, the combined number of cases of syphilis, gonorrhea, chlamydia, acute hepatitis, and active tuberculosis seen at your facility must be greater than 1,000 in the most recent 12-month period. If your facility meets the threshold and you are interested in reporting data to this registry, contact Sita C. Smith at sita.c.smith@state.ma.us.
At this time, the MDPH has not declared the Prescription Drug Monitoring Program (PDMP) a Specialized Registry.
Clinical Data Registry (Stage 3 Measure 5 - future program years)
Clinical Data Registry is a new Stage 3 requirement, but is not yet available in Massachusetts for Program Year 2019.
Reporting Requirements
Measure |
MU Measure Description |
Action to Meet MU Measure |
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Eligible Professionals | ||
1 |
Immunization Registry |
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2 |
Syndromic Surveillance Registry |
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3 |
Stage 3 - Electronic Case Reporting |
Claim an exclusion in 2018. Registry coming in 2019. |
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4 |
Modified Stage 2 - Specialized Registry
Stage 3 - Public Health Registry |
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5 |
Stage 3 - Clinical Data Registry |
Claim an exclusion. Registry not available. |
*CMS defines “active engagement” as any one of the following:
EPs who select YES to any of the three options should not claim any exclusions associated with that measure. Medicaid Program participants who claim an exclusion for a public health reporting measure are responsible for ensuring they meet the qualifications and retain all required documentation to fully support their attestation selection. |
Patient Volume Threshold (PVT)
To qualify, EPs must meet a 30% Medicaid Patient Volume Threshold (20% for Board-Certified Pediatricians) over a 90-day reporting period. For an overview of available PVT calculation methods, click here (i.e. Paid claims vs Enrollee; FQHC/RHC vs non-FQHC; and Individual vs Group Proxy).
PVT Calculator
Failure to properly calculate PVT is the main reason why EHR Incentive applications cycle through resubmissions. To make it easier, we advise you to use the new PVT Calculator to automatically calculate your PVT from your claims data. To learn more about how it works, click here.
To download the PVT Calculator, click on the links below. The Instructions and Overview are also embedded on tabs within the PVT Calculator. Read the instructions to get started and then follow the onscreen instructions as you go.
PVT Calculator (Version 2/19/2019) - Download to use the PVT Calculator
Instructions (Version 2/19/2019) - Download to get started
Overview (Version 2/19/2019) - Download if you are interested to learn how the PVT Calculator works
Note: The 2/19/2019 version works exactly the same way as the original 11/20/2017 version and produces the same result.
The only difference is that the instructions for providers with Patient Panels have been updated.
Note: The 2/5/19 version with this same update cannot be used because the workbook was accidentally protected. Use the 2/19/19 version instead.
2020 CHIP Factors for Eligible Professionals (Children's Health Insurance Program)
For non-FQHC/RHC, the following CHIP factor must be applied to the in-state numerator to exclude CHIP patients.
If you selected a 90 day PVT reporting period in:
- 2019: use the 2019 Calendar Year factor listed below.
- 2020: use the 2020 factor corresponding to the last day of the period.
2019 Calendar Year |
2020 Jan 1 - Mar 31 |
2020 Apr 1 - Jun 30 |
2020 Jul 1 - Sep 30 |
2020 Oct 1 - Dec 31 |
2021 Jan 1 - Mar 31 |
5.19% | 5.22% | 4.90% | 4.69% | TBD | TBD |
2019 CHIP Factors for Eligible Professionals (Children's Health Insurance Program)
For non-FQHC/RHC, the following CHIP factor must be applied to the in-state numerator to exclude CHIP patients.
If you selected a 90 day PVT reporting period in:
- 2018: use the 2018 Calendar Year factor listed below.
- 2019: use the 2019 factor corresponding to the last day of the period.
2018 Calendar Year |
2019 Jan 1 - Mar 31 |
2019 Apr 1 - Jun 30 |
2019 Jul 1 - Sep 30 |
2019 Oct 1 - Dec 31 |
2020 Jan 1 - Mar 31 |
4.67% | 4.85% | 5.03% | 5.11% | 5.19% | 5.22% |
Note: Prior Program Year CHIP factors are listed further down this page.
PVT Resources
MeHI Website Page |
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Medicaid Patient Volume for EPs |
Templates to Calculate Patient Volume by Individual EP
PVT Template |
Individual EP - Paid Claims (Updated 5-25-17) |
Templates to Calculate Patient Volume based on the Group Proxy Methodology
Group Proxy Template |
Group - Paid Claims (Updated 5-25-17) |
PVT - Prior Program Year Resources
2018 CHIP Factors for Eligible Professionals
For non-FQHC/RHC, the following CHIP factor must be applied to the in-state numerator to exclude CHIP patients.
If you selected a 90 day PVT reporting period in:
- 2017: use the 2017 Calendar Year factor listed below.
- 2018: use the 2018 factor corresponding to the last day of the period.
2017 Calendar Year |
2018 Jan 1 - Mar 31 |
2018 Apr 1 - Jun 30 |
2018 Jul 1 - Sep 30 |
2018 Oct 1 - Dec 31 |
2019 Jan 1 - Mar 31 |
4.35% | 4.44% | 4.53% | 4.58% | 4.67% | 4.85% |
2017 CHIP Factors for Eligible Professionals
For non-FQHC/RHC, the following CHIP factor must be applied to the in-state numerator to exclude CHIP patients.
If you selected a 90 day PVT reporting period in:
- 2016: use the 2016 Calendar Year factor listed below.
- 2017: use the 2017 factor corresponding to the last day of the period.
2016 Calendar Year |
2017 Jan 1 - Mar 31 |
2017 Apr 1 - Jun 30 |
2017 Jul 1 - Sep 30 |
2017 Oct 1 - Dec 31 |
2018 Jan 1 - Mar 31 |
3.93% | 4.02% | 4.07% | 4.20% | 4.35% | 4.44% |
2016 CHIP Factors for Eligible Professionals
For non-FQHC/RHC, the following CHIP factor must be applied to the in-state numerator to exclude CHIP patients.
If you selected a 90 day PVT reporting period in:
- 2015: use the 2015 Calendar Year factor listed below.
- 2016: use the 2016 factor corresponding to the last day of the period.
2015 Calendar Year |
2016 Jan 1 - Mar 31 |
2016 Apr 1 - Jun 30 |
2016 Jul 1 - Sep 30 |
2016 Oct 1 - Dec 31 |
2017 Jan 1 - Mar 31 |
2017 Apr 1 - Jun 30 |
3.20% | 3.46% | 3.67% | 3.81% | 3.93% | 4.02% | 4.07% |
2015 CHIP Factors for Eligible Professionals
For non-FQHC/RHC, the following CHIP factor must be applied to the in-state numerator to exclude CHIP patients.
If you selected a 90 day PVT reporting period in:
- 2014: use the 2014 Calendar Year factor listed below.
- 2015: use the 2015 factor corresponding to the last day of the period.
2014 Calendar Year | 2015: Jan 1 - Mar 31 | 2015: Apr 1 - Jun 30 | 2015: Jul 1 - Sep 30 | 2015: Oct 1 - Dec 31 |
2.75% | 2.76% * | 2.89% * | 3.06% ** | 3.20% ** |
Table notes:
* Q1-Q2 factors changed as of 7/8/16. If you submitted before 7/8/16, you will only need to update your application if we ask you to do so.
** Q3-Q4 factors are new as of 7/8/16. If you submitted before 7/8/16 using an estimated factor, you will be asked to update the application.
Medicaid EHR Incentive Program - Validation and Audits
All Medicaid EHR Incentive Program applications will go through a pre-payment validation process. After the incentives have been paid, the provider may also be selected for a post-payment audit. The audits are performed by EOHHS, or their contractors. For audit purposes, all supporting documentation must be retained for at least six years after attestation.
Pre-Payment Validation Resources |
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MeHI Website |
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Post-Payment Audit Resources |
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CMS Fact Sheet |
Audit Overview (Last update Feb 2013) |