Supporting Documentation

Required Supporting Documentation for Attestation in the PI Program

On this page you will find a checklist of supporting documentation information for attestation to the Medicaid PI Program. Please read all of the points to find notes on what is required to pass the review process. You can download a printable version of this checklist for your convenience.

General Documentation:

  • Patient Encounter List (PEL)
    • This needs to be in an Excel file format, and should be completed using the PEL Template.
    • The dates of service in the file must be within the 90 day Patient Volume reporting period.
    • The file must include all patient encounters that occurred during the 90 day period. A patient encounter is defined as any encounter where a medical treatment is provided or evaluation and management services are provided.
    • There must be a column for each of these exact headers:
      • Date of Service
      • Patient First Name
      • Patient Last Name
      • Date of Birth
      • Medicaid ID (when applicable)
      • Payer (insurance name or self-paid)
      • Service Provider NPI.
    • Duplicates need to be removed. You can use the formula provided in the template above to find any duplicates.
    • The Patient Volume percentage (total Medicaid patients/total patients) must be 30% or above (or 20% or above for pediatricians).


  • Purchase Order/Invoice
    • There needs to be a proof of purchase (not license agreement) indicating that the provider has paid for the EHR system within the program year.
    • It should indicate agreement between the provider/practice and the vendor of the EHR system.
    • There should be a total purchase price on the document (redacted is acceptable).
    • If the EHR system is free, there should be a letter from the vendor indicating this.


  • CEHRT/Cart Page
    • You can confirm your EHR technology is certified and find the CEHRT/Cart Page here: ONC Certified Health IT Product List (CHPL).
    • This document must show that the EHR technology is version 2014 or later. If you are attesting to Meaningful Use Stage 3, it must show certification from 2015 or a mix of 2014 and 2015 certification that still allows the EP to complete the Stage 3 requirements.
    • It must contain the Product Certification Number, Product Name, and Vendor Name.
    • Make sure the CEHRT ID you entered in MAPIR matches the one on this page.
    • This is an example of what the Cart Page should look like. You can find instructions for the website here.


  • Security Risk Assessment (SRA) Checklist
    • For 2018, please upload one of the following:
      • A security risk analysis done by the EHR itself or by staff at the facility. This must be in line with the guidelines set by the state. For more information, please see the Security Risk Analysis Presentation and this tipsheet.
      • A security risk analysis as outlined on the ONC website using this tool.
    • The Security Risk Analysis that is required is the full comprehensive report, including all the guidelines within. This is the document that you based the checklist off of. The SRA checklist will not be accepted as substitute for your SRA. 


Meaningful Use Documentation:

  • MU and CQM CEHRT Reports
    • These must be clearly generated from your EHR technology and they must be legible.
    • You should have at least one document for the Objectives and at least one document for the Clinical Quality Measures.
    • Each document should contain the Provider Name, Name Identifier, or NPI. It should also contain Measure Identifiers, and a 90-day Meaningful Use period matched to the one entered in MAPIR.
    • You must attest to 3 out of 6 National Quality Strategy Domains for the Clinical Quality Measures.


  • Objective 10 Supporting Documentation
      • FOR PROGRAM YEAR 2018
        • Connecticut Immunization Registry and Tracking System (CIRTS) will be shut down and the data is now migrated to the new Immunization Information System (IIS) called “CT WiZ”. We are still in the process of updated them, so you will see more updates throughout the upcoming weeks.
      • Contact Us webpage has Helpdesk: Submit a request (fillable form).
      • If you are in active engagement with a specilized registry, you need to provide some sort of documentation, like a registration letter, to support your attestation.



  • Must Portal (Objective 10 Measure 1)
  • Syndromic Surveillance (Objective 10 Measure 2)
    • Connecticut Department of Public Health (DPH) is not currently ready to receive syndromic surveillance data to meet the CEHRT standards. Connecticut EPs should exclude from this measure.
  • Specialized Registry (Objective 10 Measure 3)
    • You may exclude from this measure for three reasons:
      • The EP does not diagnose or treat any disease or condition associated with, or collect any relevant data that is required by a specialized registry in their jurisdiction.
      • The EP operates in a jurisdiction for which no specialized registry is capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition.
      • The EP operates in a jurisdiction where no specialized registry for which the EP is eligible has declared readiness to receive electronic registry transactions.


  • Other Core Objective Exclusions
    • If you are excluding from any Core Objectives 1 through 9, you do not need to provide any additional information in the application. However, you may be asked for proof of why you excluded during a post-payment audit.