What You Need to Know and Important Reminders: 

For all Eligible Professionals (EP), the Objective & Clinical Quality Measure (CQM) reporting period is any 90-days in 2021. The EHR reporting period for new and returning participants to the CMS is a minimum of any continuous, self-selected, 90-day period.   

CMS will allow attestation prior to completion of the annual Security Risk Assessment (SRA) and must be completed by December 31, 2021.

Before You Submit 

Make sure you have sufficient and dated supporting documentation, as in the following example list. This is not a fully comprehensive list as we recommend verifying any unique requirements with your state administrator. 

• Clinical Decision Support Screen Shots or supporting documentation/letters 

• Evidence of a completed SRA 

• Patient Volume Reports from your qualifying encounter period in CY 2020. Make sure all necessary details are included in the report. Necessary detailed examples could include: Primary/Secondary Payer Information, Encounter Number, Encounter Date, Rendering, Person Number 

• Save electronically and as a hard copy all Eligible Professional Reporting Data (Objectives and CQMs) 

• CEHRT Letter demonstrating compliant version and potentially a contract/agreement that demonstrates financial obligations 

All EPs should have participated and are registered in CMS Registration and Attestation and your state-based Promoting Interoperability Programs. 

Clarify that there will be an organization administrator completing attestations on behalf of the Eligible Professional (delegate/surrogate) and that individual has an Identity & Access account with CMS.  

Be diligent in your documentation and keep records for the recommended seven-year period to prepare for the event of an audit. Thorough document retention can be the difference between meeting an audit request or potentially paying an incentive payment.