Description
The MIPS-eligible clinician is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).
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- If you are a small practice (with 15 or fewer clinicians billing under the practice's TIN) - You must take the automatic Promoting Interoperability reweight. To take this, simply ensure your providers DO NOT submit Promoting Interoperability data to CMS in for the 2022 reporting period.
- If you are part of a large practice or reporting as a large practice group (more than 15 clinicians billing under the practice's TIN), you need to submit a Promoting Interoperability hardship exception application here.
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DrChrono will certify to § 170.315 (f)(1) Transmission to immunization registries for 2023 reporting.
Definitions
Active engagement - The MIPS-eligible clinician is in the process of moving towards sending "production data" to a public health agency or clinical data registry or is sending production data to a public health agency (PHA) or clinical data registry (CDR).
Active engagement may be demonstrated in one of the following ways:
- Option 1 - Completed Registration to Submit Data: The MIPS eligible clinician registered to submit data with the PHA or, where applicable, the CDR to which the information is being submitted; registration was completed within 60 days after the start of the MIPS performance period; and the MIPS eligible clinician is awaiting an invitation from the PHA or CDR to begin testing and validation. This option allows MIPS-eligible clinicians to meet the measure when the PHA or the CDR has limited resources to initiate the testing and validation process. MIPS-eligible clinicians that have registered in previous years do not need to submit an additional registration to meet this requirement for each MIPS performance period.
- Option 2 - Testing and Validation: The MIPS-eligible clinician is in the process of testing and validation of the electronic submission of data. MIPS-eligible clinicians must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a MIPS performance period would result in that MIPS-eligible clinician not meeting the measure.
- Option 3 - Production: The MIPS-eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.
Production data - Refers to data generated through clinical processes involving patient care, and it is used to distinguish between data and "test data" which may be submitted for the purposes of enrolling in and testing electronic data transfers.
Exclusions
Any MIPS-eligible clinician meeting one or more of the following criteria may be excluded from the Immunization Registry Reporting measure if the MIPS-eligible clinician:
- Does not administer any immunizations to any of the populations for which data is collected by its jurisdiction's immunization registry or immunization information system during the performance period. OR
- Operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required to meet the CEHRT definition at the start of the performance period. OR
- Operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data as of 6 months prior to the start of the performance period.
You can select your attestation or exclusion in your Healthmonix MIPSpro account.
