Electronic Prescribing (eRx) Incentive Program Analysis and Payment

Each year, the Electronic Prescribing (eRx) Incentive Program incentive payment and the eRx Incentive Program feedback report are issued through separate processes. ERx Incentive Program feedback report availability is not based on whether or not an incentive payment was earned. Feedback reports will be available for every TIN under which at least one eligible professional (identified by his or her National Provider Identifier, or NPI) submitting Medicare Part B PFS claims reported at least one valid eRx Incentive Program measure a minimum of once during the reporting period. ERx Incentive Program participants will not receive claim-level details in the feedback reports.

Incentive Payments

Eligible professionals who participate in the eRx Incentive Program by reporting on their adoption and use of a qualified eRx system that has the functionalities required by CMS may qualify for an incentive payment.

MIPPA authorized incentive payments through 2013. Below are the authorized amounts for each program year:

• 2009 eRx – 2.0%
• 2010 eRx – 2.0%
• 2011 eRx – 1.0%
• 2012 eRx – 1.0%
• 2013 eRx – 0.5% (last year for eRx incentive payment)

Please note that the Medicare Improvements for Patients and Providers Act of 2008 (known as MIPPA) also requires CMS to subject eligible professionals who are not successful electronic prescribers to a payment adjustment beginning in 2012 through 2014. Click on the following link for additional information can be found by clicking ion the following link to the Payment Adjustment Information section page.

The eRx incentive payment is similar to the Physician Quality Reporting System incentive in that it is based on the Medicare Part B Physician Fee Schedule (PFS) covered professional services furnished by the eligible professional during a reporting period. To be eligible for the incentive, you must meet the criteria for being a successful electronic prescriber. The criteria used to determine whether an eligible professional is a successful electronic prescriber are established for each program year through rulemaking.

Incentive payments for each program year are issued separately as a single consolidated incentive payment in the following year. Incentive payments are issued to the first valid group location listed under the Taxpayer Identification Number (TIN); or, for solo practitioners, to the first valid practice location listed under the TIN. The Medicare claims-processing contractors (Carrier/MAC) will make the payment electronically or via check, based on how the TIN normally receives payment for Medicare Part B PFS covered professional services furnished to Medicare beneficiaries. If a TIN submits claims to multiple Carriers/MACs, each contractor may be responsible for a proportion of the TIN incentive payment equivalent to the proportion of Medicare Part B PFS claims the contractor processed during the applicable reporting period. (Note: If splitting an incentive across contractors would result in any contractor issuing an eRx incentive payment less than $20 to the TIN, the incentive will be issued by fewer contractors than may have processed PFS from the TIN for the reporting period). The eRx incentive payment can be offset by an outstanding debt for the TIN.

The incentive payment, with the remittance advice, will be issued by Carrier/MAC and identified as a separate payment under the eRx Incentive Program. Medicare contractors will use the indicator of LE (“Levy”) to indicate federally mandated payments. LE will appear in the PLB-03-1 segment of the 835. In an effort to further clarify the type of incentive payment issued LE will appear on the remit, along with a 4-digit code to indicate the type of incentive and reporting year.

For example, eligible professionals will see the LE to indicate an incentive payment, along with RX10 to identify that payment as the 2010 eRx incentive payment. Additionally, the paper remittance advice will read, "This is an eRx incentive payment." The year will not be included in the paper remittance.

Once we begin distributing incentive payments for a particular program year and if your incentive does not arrive or the incentive payment amount does not match what is reflected in your eRx Incentive Program feedback report, contact your Carrier/MAC (click on the "Help Desk Support" link at left for contact information). Note: The incentive amount may differ by a penny or two from what is reflected in your feedback report due to rounding.

Important Notice!  Sequestration and the  Electronic Prescribing (eRx) Incentive Program

Incentive payments made through the eRx Incentive Program are subject to the mandatory reductions in federal known as sequestration, required by the Budget Control Act of 2011. The American Taxpayer Relief Act of 2012 postponed sequestration for 2 months. As required by law, President Obama issued a sequestration order on March 1, 2013. Under these mandatory reductions, 2013 eRx Incentive Program incentive payments made to eligible professionals and group practices will be reduced by 2%. For example: An EP has $100,000 in allowed charges. The 0.5% (0.005) incentive = $500. The $500 incentive will be reduced by 2% ($500 x 0.02= $10), so the total incentive payment with sequestration would be $490. This 2% reduction will be applied to any eRx Incentive Program incentive payment for a reporting period that ends on or after April 1, 2013.  Since the 2013 reporting period ends after this date, incentive payments for this reporting period are subject to sequestration. Incentive payments for prior reporting periods will not be subject to the reduction.

2013 PQRS and/or eRx Incentive Program: Stripped N365 Remark Code

For those eligible professionals participating in the 2013 Physician Quality Reporting System (PQRS) and/or Electronic Prescribing (eRx) Incentive Program via claims, CMS is aware the Remittance Advice (RA)/Explanation of Benefits (EOBs) may not be displaying the N365 remark code for program quality-data codes (QDCs) for claims processed April 2013 through July 2013. The N365 remark code will reappear again starting for claims that are processed in July 2013. QDCs submitted on Medicare Part B Physician Fee Schedule (PFS) claims with $0.00 line items have been (and will be) processed into the National Claims History (NCH) file even though the RA/EOB did not indicate the N365 remark code, given the claim was in final-action status and not pended, rejected, etc.

What should I do if I don’t see the N365 Remark Code?
The N365 remark code on the RA/EOB is an indication that the QDC is associated with current program year PQRS and/or eRx Incentive Program specifications, but does not confirm whether the QDC was accurately reported per program requirements. If the QDC $0.00 line item shows on the RA, but without the N365, it is possible the QDC is not within current program year specifications. It is also possible that the N365 is simply missing due to reporting using the $0.00 line item. All submitted QDCs on fully processed claims are forwarded to the NCH for analysis by the PQRS and/or eRx programs, so providers will first want to be sure they do see the QDC line item on the RA/EOB, regardless of whether the N365 appears. If there is no QDC line item, it is possible that the provider’s claims software has stripped any $0.00 line items, and this will need to be corrected, either within the software, or by adding a $0.01 charge rather than $0.00.

Adding the $0.01 charge to the QDC line item will help generate the N365 remark code, which will indicate whether the QDC is current. Providers may work with their vendors/billing systems/clearing houses to determine whether the option to submit a $0.00 or $0.01 charge for QDC line items will work best for their practice.

Tips for Reporting

CMS would like to remind providers that no PQRS/eRx Incentive Program reporting validation or analysis occurs at the Carrier or A/B Medicare Administrative Contractor (MAC) claims level, beyond forwarding QDCs to the NCH. So it is imperative that providers make sure they are coding claims with the current program year measure specifications, either for individual measures or measures groups. They will want to verify that the patient they are reporting on falls within the measure’s denominator for age/gender, as well as diagnosis and service/encounter when applicable. Then be sure to follow the specifications showing the available numerator QDC reporting options, and report the one(s) that best describes the quality action performed.

Again, CMS is aware that RA/EOBs may not display the N365 remark codes for $0.00 QDC line items and is actively working with Carrier/Medicare Administrative Contractors (MACs) to resolve this issue. The N365 remark code will reappear again with claims that are processed after July 2013.

2014 eRx Payment Adjustment

2014 eRx Payment Adjustment Feedback Report User Guide

A quick reference guide for understanding the 2014 eRx Payment Adjustment Feedback Report has been posted in the "Downloads"section below.  The 2014 eRx Payment Adjustment Feedback Report User Guide is designed to assist eligible professionals, group practices participating in eRx Group Practice Reporting Option (GPRO), and their authorized users in accessing and interpreting the 2014 eRx Payment Adjustment Feedback Report.

2013 eRx Payment Adjustment

2013 eRx Informal Review Made Simple

This Fact Sheet provides step-by-step guidance for requesting an informal review of 2013 eRx Incentive Program results during the informal review period, January 1, 2015 through February 28, 2015.  To review this document click on the following link: 2013 eRx Informal Review Made Simple(PDF) (PDF).

2013 eRx Feedback Report User Guide

A quick reference guide for understanding the 2013 eRx Feedback Report has been posted to this section page. The eRx Feedback Report User Guide is designed to assist eligible professionals (EPs), group practices, and their authorized users in accessing and interpreting the 2013 eRx Incentive Program feedback reports.  To review this user guide click on the following link: 2013 PQRS Feedback Report User Guide(PDF) (PDF).

2013 eRx Payment Adjustment Feedback Report User Guide

A quick reference guide for understanding the 2013 eRx Payment Adjustment Feedback Report has been posted in the "Downloads"section below.  The 2013 eRx Payment Adjustment Feedback Report User Guide is designed to assist eligible professionals, group practices, and their authorized users in accessing and interpreting the 2013 eRx payment adjustment feedback report.

2012 eRx Incentive Program

2012 eRx Incentive Program Informal Review Made Simple

This Fact Sheet provides step-by-step guidance for those eligible professionals and eRx GPROs who wish to request an informal review of 2012 eRx Incentive Program results during the 2013 calendar year. This document applies only to 2012 eRx Incentive Program incentive payment eligibility, and does not provide guidance for the eRx payment adjustments or other Medicare or Medicaid incentive programs, such as the Maintenance of Certification Program or the Electronic Health Record (EHR) Incentive Program. To view click on the following link 2012 eRx Informal Review Made Simple(PDF) (PDF).

A Guide for Understanding the 2012 Electronic Prescribing (eRx) Incentive Program Incentive Payment

CMS has posted a guide for understanding your 2012 eRx incentive payment. This document describes how the 2012 eRx Incentive Program incentive payment was calculated for 1) individual eligible professionals, and 2) self-nominated and CMS-selected eRx Group Practice Reporting Option (GPRO) participants.  To view click on the document titled "2012 eRx Incentive Payment User Guide"in the "Downloads"section below.

2012 Electronic Prescribing (eRx) Incentive Program Feedback Report User Guide

The Electronic Prescribing (eRx) Incentive Program Feedback Report User Guide is designed to assist eligible professionals, CMS-selected group practices, and their authorized users in accessing and interpreting the 2012 eRx Incentive Program feedback reports. For the 2012 eRx Incentive Program, the feedback reports reflect data from the Medicare Part B Physician Fee Schedule (PFS) claims received for the dates of service January 1, 2012 – December 31, 2012 that were processed into National Claims History (NCH) by February 22, 2013. Additionally in 2012, quality data was received from qualified registries and EHR systems for purposes of the eRx Incentive Program. The 2012 eRx incentive payment is scheduled to be distributed in the fall of 2013.  To view click on the document titled "2012 eRx Feedback Report User Guide"in the "Downloads"section below.

Location of Previous Program Year Documents

All previous program year documents will be moved from this page to that specific program year section page at left.