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Medicaid Patient Volume and Hospital-Based Eligibility

Medicaid Patient Volume
Eligible Professionals (EPs) may choose one (or more) clinical sites of practice to calculate patient volume (i.e., the calculation does not need to be across all of an EP's sites of practice). However, at least one site at which the EP is adopting or meaningfully using certified EHR technology must be included in the patient volume.

New Hampshire implemented Managed Care Organizations on December 1, 2013. Providers should include managed care encounters in their patient volume attestations. New Hampshire Managed Care Organizations include Well Sense; Meridian; and NH Healthy Families.

  • Patient Volume reporting period: any continuous 90-day period during the calendar year prior to the payment year.
  • Denominator: all encounters that the EP provided during the Patient Volume reporting period.
  • Numerator: all services (in the denominator) provided in a day by a specific provider to a Medicaid-enrolled individual during the Patient Volume reporting period. This includes:
    • Services in which Medicaid or Medicaid Managed Care programs (including out-of-state programs) paid for part or all of the services (including premiums, co-payments, and/or cost sharing); or
    • Encounters where Medicaid paid zero dollars where Medicare (in the case of patients that are dually eligible for both Medicaid and Medicare) or another third party paid for the encounter; or
    • Encounters provided to Medicaid beneficiaries for which no payments were received; or
    • Medical services provided to Medicaid beneficiaries that were not covered under New Hampshire's Medicaid program.

Hospital-based Criterion
This criterion is applicable only to EPs that attest to Medicaid patient volume. These EPs must attest that they are not hospital-based, i.e., do not provide more than 90 percent of their Medicaid covered professional services in a hospital setting. In the New Hampshire Medicaid EHR Incentive Program, a hospital setting is defined as Medicaid encounters at Place of Service (POS) codes for HIPPA standard transactions 21 (Inpatient Hospital) and 23 (Emergency Department).

The Medicaid hospital-based criterion is calculated using each individual EP's encounters data. (EPs may not use group data to attest to this criterion.)

  • Hospital-based reporting period: the calendar year prior to the payment year.
  • Denominator: total Medicaid encounters at all locations that the EP provided during the hospital-based reporting period.
  • Numerator: all Medicaid POS 21 and Medicaid POS 23 encounters that the EP provided during the hospital-based reporting period.

The hospital-based criterion is not applicable to EPs in Federally Qualified Health Centers and Rural Health Centers that attest using Needy Individual patient volume encounter data.

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New Hampshire Department of Health and Human Services
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