Maine Health Management Coalition - Pathways to Excellence Program
Provider Attestation of Ineligibility Form / “Unable to Determine” Reporting Status
(For Excluding Providers from Calculation of Practice Level Ratings for the GetBetterMaine Website)
Exclusion of providers from calculations of practice level ratings is a temporary rating designation for providers that are
ineligible to report to a national clinical recognition program. The practice must attest that the provider is ineligible for one of
three reasons:
 Provider has not been with their current practice for more than one year (which renders them ineligible to claim
responsibility for their patient panel’s outcomes);
 Provider does not have a large enough panel of patients to meet the criteria for the recognition in question. The
eligibility requirements for the clinical recognition programs can be found as follows - Bridges to Excellence (BTE)http://www.hci3.org/recognition_programs) or the National Committee on Quality Assurance (NCQA)http://www.ncqa.org/Programs/Recognition.aspx;
 Provider does not carry their own panel of patients, and is therefore ineligible for individual recognition (although we
do encourage practices with providers in this circumstance to apply as a group).
Practices will be responsible for submitting an updated attestation form to renew the documentation of a provider’s inability
to meet the criteria in accordance with the following time frames:
 Provider has not been with their current practice for more than one year - No additional documentation needs to be
submitted for this attestation. After one year, the provider who was originally attested out of the practice level rating
calculation will automatically be included in the practice level rating calculation, unless an attestation for another
reason is submitted (e.g., the provider has too few patients);
 Provider does not have a large enough panel of patients to meet the criteria for the recognition in question - This
attestation must be updated biannually (every two years). After two years, the provider who originally attested out of
the practice level rating calculation will automatically be included in the practice level rating calculation, unless an
attestation is resubmitted certifying that the provider still has too few patients for a specific recognition;
 Provider does not carry their own panel of patients - No additional documentation needs to be submitted for this
attestation. If a provider does not have their own panel of patients, they will indefinitely not be included in the
practice level rating calculation. However, if we do receive notification via our data feed that they received recognition
from a national clinical recognition program, we will contact the practice to confirm whether or not the provider has
their own panel of patients. If they do, or if we receive other information that indicates that they do, this will be
updated and the provider will be included in the practice level rating calculation.
If an updated attestation is not received in accordance with the time frames and circumstances described above, the originally
attested provider will be considered eligible and added back into the denominator for practice level rating calculations. See the
PTE Physicians Policies and Procedures document on our website for more information about this process.
Maine Health Management Coalition
11 Bowdoin Mill Island, Suite 260
Topsham, ME 04086
207-844-8106 / [email protected]
***PLEASE ONLY RETURN THIS PAGE WHEN SUBMITTING; DO NOT RETURN PAGE 1***
This form must be filled out for each individual provider that is completing an Attestation of Ineligibility
Date: __________________________________________________________________________
Practice Name: _________________________________________________________________
Address: _______________________________________________________________________
Provider Name: _________________________________________________________________
Exclusion of providers from the calculation of practice level ratings is being requested for this provider because:
 New to the Practice* – Please enter Start Date: ___________________________________
(Provider will remain ineligible until one year after their start date)
 Not Eligible for Clinical Recognition Due to Insufficient Patient Panel Size:
Circle One – submit a separate form for each recognition being attested to:
Diabetes, Spine Care, Asthma, Depression, Cardiac Care, Coronary Artery Disease, Congestive Heart Failure, COPD,
Hypertension
Please also complete the following:
1. Number of qualified patients in this provider’s patient panel for the clinical recognition circled above (for
example, the number of patients with diabetes when referencing the Diabetes Recognition):____________
2. Number of qualified patients required by the recognition program to qualify for this
recognition: ______________
3. Total number of providers at this practice*: __________
 Ineligible Because Provider Doesn’t Carry Own Patient Panel:
Please Explain: __________________________________________________________
Physician Leader Attestation (or Representative Approved to Sign on Behalf of Physician Leader): I have reviewed the data
submitted in this attestation and agree that it is a correct assessment of this practice. I also understand that our practice may be
selected for an audit.
Signature: _____________________________________
Date: ____________________________
Name and Title (Please Print): ________________________________________________________
Contact Number and Email Address: _______________________________________________
Please email this form to [email protected] (preferred) or fax to the MHMC office at 207-844-8115
*Opportunity to Add/Remove Providers and Update Website Information:
The Maine Health Management Coalition strives to keep demographic information up-to-date on the GetBetterMaine website. Please complete a Practice
Update Form using the link below for all new providers. We also request you take a few moments to review your information on our website periodically
and to provide any updates using this link: http://www.mehmc.org/download-pte-materials/
Maine Health Management Coalition
11 Bowdoin Mill Island, Suite 260
Topsham, ME 04086
207-844-8106 / [email protected]