Eligible Professionals (EPs) must calculate their Medicaid Patient Volume (PVT) over a 90-day PVT Reporting Period*. Determining PVT is complex and failure to properly calculate PVT is the main reason why EHR Incentive applications cycle through resubmissions. To simplify the PVT calculation, MeHI has developed the PVT Calculator to automatically calculate the PVT from your claims data.
We recommend using the PVT Calculator to accurately calculate your PVT before attestation. The tool will enable you to upload PVT Supporting Documentation into MAPIR, when requested during the validation process. Our analysts use the PVT Calculator to validate PVT, so by using the tool you may help expedite your payment approval.
The PVT Calculator is easy to use with lots of onscreen instructions and help, see picture below. Users reported they mastered the PVT Calculator and accurately completed their PVT in 10 to 30 minutes. It is that easy, and can be used Free of Charge, so why not use it?
* The PVT Reporting Period must be, selected from either the previous calendar year or the 12 months leading up to the date of attestation.
To qualify for EHR Incentives, the PVT must meet the 30% PVT Threshold requirement (20% for Board-Certified Pediatricians).
Download PVT Calculator
The PVT Calculator contains three tools. Feature summaries are included for each tool further down this page:
• PVT Calculator: Determines the PVT based on One Claim, Per Patien, Per Day, Per EP;
• Multiple Payors Converter: Adapts an encounter-based format to the claims-based format;
• Group Roster Creator: Pre-populates the group roster with all the provider information included in the claims detail.
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.
Download Claims Data Templates
PVT must be calculated based on one service, per patient, per day, per EP. Health services are typically recorded as a claim and sent to Payors, like Medicaid, Managed Care Organizations, and Commercial Insurance. Claims data can serve as a proxy for the services EPs provide, and includes the information needed to determine whether an EP satisfied the required PVT eligibility threshold.
As such, the PVT Calculator determines PVT as: "Total Eligible Medicaid Claims (Numerator) divided by Total Claims (Denominator)". In this calculation, all the PVT rules are automatically applied. The PVT Calculator can handle many MS Excel and CSV claims formats, though for best practice we recommend using the claims templates below:
Individual EP - Paid Claims (Updated 5-25-17)
Individual EP - Enrollee (Paid, Zero Paid, and Denied Claims) (Updated 5-25-17)
Group - Paid Claims (Updated 5-25-17)
Group - Enrollee (Paid, Zero Paid, and Denied Claims) (Updated 5-25-17)
Feature Summary of PVT Calculator
This feature summary provides insight into what the PVT Calculator can do. Reading the summary may help you to operate the tools.
All you have to do is CLICK, and your PVT will Appear
For many EPs it will be as simple as a few CLICKS. To prepare, create your claims report, start the PVT Calculator, browse and Click to import your claims file, enter a few fields to describe your data layout, and Click to identify your Medicaid Payors. Click again to run the PVT Calculation, and voila within seconds your PVT will appear.
The PVT Calculator will identify missing data, highlight duplicate claims, and find other potential data issues. All this is done without you building complex MS Excel formulas. You will still be required to analyze the accuracy of the PVT, just as if you did the work yourself, but the PVT Calculator makes it easy for you to recognize the areas of concern.
Beginner and Expert Mode
To make it even easier, the PVT Calculator comes with Beginner and Expert modes. In Beginner mode, The PVT Calculator will guide you through the PVT process with step by step pop-up instructions. When you no longer need these instructions, you can turn them off by selecting Expert mode. In Expert mode, you will only see pop-up instructions for issues you need to address.
Individual and Group Proxy PVT Calculation
The PVT Calculator can calculate:
The PVT of an Individual EP:
• The claims data must include only the claims of the individual EP; and
• does not need to include the EP's NPI or Name.
The PVT aggregated across all providers in a Group Proxy*:
• The claims data must include the claims of all providers in the group, including the ineligible providers; and
• must include the NPI or unique Names of all eligible and ineligible providers in the group.
* When using Group Proxy, none of the EPs in the group can attest with Individual PVT. All EPs in the group must attest with the same aggregated PVT!
Paid Claims and Enrollee Methodologies
PVT Calculator lets the user select from the two available PVT calculation methodologies. Based on the chosen methodology, the PVT Calculator automatically sorts through the encounter details to determine which claims to include in the PVT Numerator and Denominator.
Paid Claims Method:
PVT Numerator: will include all claims paid, in part or full, by Medicaid and MCOs.
PVT Denominator: will include all claims paid by Medicaid and all other payors.
- Enrollee Method*:
PVT Numerator: will include all eligible Medicaid and MCO claims whether paid, or not (Zero-Paid claims).
PVT Denominator will include all claims regardless of whether these were paid.
* Using the Enrollee Methodology may increase PVT if any Medicaid services were provided for free.
Automated Identification of Medicaid Claims (Paid Claims and Enrollee Methodologies)
The PVT Calculator scans through the claims data to create a table of the Payors included in the claims data. In this Payors table, you can quickly identify the Medicaid Payors. The PVT Calculator uses the table to sort through the data to find the Medicaid claims.
Automated Identification of Eligible Zero-Paid Claims (Enrollee Methodology)
For the Enrollee Method, the PVT Calculator scans through the claims data to create a table of the Denial Reasons of Zero-Paid claims. In this Denial Reasons table, you can identify which Zero-Paid claims were ineligible for Medicaid. The PVT Calculator uses the table to automatically exclude the ineligible Zero-Paid claims.
Automated Multiple Encounter Deduping
To calculate PVT from claims data, the "one service, per patient, per day, per EP" must be interpreted to mean "one claim, per patient, per day, per EP". In other words, only one claim can be counted per day. Additional claims resulting from multiple encounters with the same patient on the same day must be excluded. PVT Calculator automatically excludes additional claims in a process called Deduping.
Automated Multiple Payor Deduping
A single patient encounter can result in claims to multiple Payors. For instance, a portion may be paid by Medicaid, while the rest is paid by a different health insurance. You can choose to use either Primary-Payor-only claims data, or Multiple-Payor claims data*.
To calculate PVT properly from Multiple-Payor claims data, only one of the claims can be counted per day. If Medicaid is one of the Multiple Payors, the Medicaid claim should be counted. PVT Calculator automatically makes this selection in the Deduping process.
* Using Multiple-Payor claims data may increase PVT if Medicaid frequently was the Secondary Payor.
FQHC/RHC, Non-FQHC and CHIP Factor Handling
EPs are considered to practice predominately at an FQHC or RHC if 50% or more of their encounters over a 6 month period in the current calendar year occur at an FQHC or RHC. These EPs can attest as FQHC/RHC or Non-FQHC EPs. All others must attest as Non-FQHC EPs.
Which claims can be included in the PVT Numerator depends on whether an EP practices predominantly at an FQHC or RHC, as shown in the table below. PVT Calculator handles FQHC/RHC EPs versus Non-FQHC EPs as follows:
Non-FQHC: Only Medicaid claims are counted in the PVT Numerator and the CHIP Factor* is applied to the Numerator.
- FQHC/RHC: Medicaid and Needy Individual** claims are counted in the PVT Numerator and the CHIP Factor is not applied.
* The CHIP Factor excludes an average number of Children's Health Insurance Plan encounters, as these are not eligible for EHR Incentives.
For the PVT to be calculated correctly, you have to enter the CHIP Factor applicable to the PVT Reporting Period.
** Zero-Paid Needy Individual claims need to be identified in the claims data before using the PVT Calculator, as explained in the Instructions.
Medicaid and Needy Individual patients to be counted in the PVT numerator
|FQHC / RHC||Non-FQHC|
Medicaid Population (FFS)
Medicaid 1115 Waiver Population (MCO)
Services furnished at no or reduced cost based on individual’s ability to pay
Apply CHIP Factor to exclude Children's Health Insurance Program encounters
Practitioner Panel PVT Calculation
The PVT Calculator can calculate the PVT of a Practitioner Panel. However, because this PVT formula is only partially based on claims data, you need to add and define the Panel Patients into the claims file, as explained in the Instructions.
Feature Summary of Multiple Payor Converter
In the past, EPs were asked to include multiple Payors on a single row in their claims file, where each row represents a patient encounter. This is no longer necessary, because PVT Calculator's Deduper algorithm expects each Payor to be listed on a separate row.
If your claims are listed in the old format, you can use the Multiple Payors Converter tool to transform your old format into the new claims format required by the PVT Calculator. The converter can handle up to four Payor columns in the claims data, see picture below.
Feature Summary of Group Roster Creator
EPs who attest with Group Proxy PVT must submit a group roster that includes all providers included in the PVT calculation. PVT Calculator contains a tool to semi-automatically create the required roster from your claims data.
PVT Calculator highlights the roster data found in the claims data, and the missing information can be added manually, see picture below. With the click of a button, the roster can be sorted by provider Name or NPI.
Get Started Today!
For assistance, call or email MeHI's Medicaid EHR Incentive Program staff, Mon through Fri from 9:00am to 4:30pm:
The PVT Calculator program is the copyright of the Massachusetts EOHHS (Executive Office of Health and Human Services) and MeHI (Massachusetts eHealth Institute at MassTech). The program was created by MeHI, on behalf of the Massachusetts EOHHS. PVT Calculator can be downloaded for free from the MeHI website for the purpose of participation in the Medicaid EHR Incentive Program. The program cannot be redistributed for any other purpose and cannot be altered in any way without the written consent of MeHI and the Massachusetts EOHHS.
Notice of Responsibility
The PVT Calculator program is designed to enable EPs or their Designees to calculate their PVT. However, without exception, Medicaid EHR Incentive Program compliance remains the sole responsibility of the EP. The requirements are defined by CMS and MassHealth and cannot be overruled by the PVT Calculator. No claims of PVT accuracy can be made based on the results of using the PVT Calculator. The EP and Designee remain solely responsible for the accuracy of the PVT, and must verify the details and results of the PVT calculation. The EP and Designee need to make sure all data entered into PVT Calculator is correct and complete. While PVT Calculator will highlight missing or zero claims data, the EP and Designee are responsible for correcting highlighted or other data as applicable. After changing any data, the EP or Designee must rerun the PVT Calculator.