Adrienne Adkins

Ahmar Wazir

Arnie Esparterox
Betina Fletcher
Bridget Calvert
Cheri Jergerx
Chris Brownx
Christopher King
Curtis Phillipsx
Deb Wilsonx
Dianna Christensenx
Greg Eccleston
Hari Krishna Pemmasani
Heather Moorex
Howard Thomasx
Janet Lea Hutchinsonx
Jason Bullock
Jason Clemx
Jason Simmington
Jennifer Baileyx
Justyna Sardin
Karena Sx
Kathleen Prewittx
Kelly Llewellynx
Kelly Mayo
Leah Skrienx
Lisa Reesx
Martha Beanx
Melissa Fieldhousex
Michael Kennedy
Nathan Muzos
Pandu Muddana
Rachelle DuBose Caruthersx
Revathy Ramakrishnax
Sarah Fillingx
Seema Sreenivas
Shalon Quinnx
Tracey Coleman
Vladimir Ladik


  • Call will be recorded for the purpose of capturing further meeting notes.  Any objections please inform the host
  • Lisa would like to clarify regarding MDS data
    • The MDS data being incorporated on the first run is not true
    • The MDS data is a phase 2 enhancement
2021 Data SubmissionsAhmar
  • What is everyone's thought in terms of the timeline?
  • Mentioned in last Friday's EDI Submissions call the program is considering some options as to what the clinical closure deadlines should be
  • Currently thinking to open up all he clinical months up for 2021 at the same time
  • Opening January through September all at the same time giving the EDIs the flexibility to submit as much data as they can
  • Also thinking about putting our the closures for every quarter; the first quarter of 2021 going to put a closure off and give the EDIs 45 days for that, so from January through March of 2021 they will have 45 days to submit the data
  • Everything until September will be open and when October 1st comes they will open the clinical month of October as well
  • Same for November.  When November starts, they will open November clinical month
  • NRAA -
    • Approach of closing quarters on a rolling basis sounds fine
    • They do not think 45 days is enough time
    • They have been trending weekly since reopened for 2020 and they barely have enough time to complete
    • Request to open Q1 for 90 days; 60 days for Q2 and then 60 more days for Q3
    • Then a normal cadence of closing 60 days after the end
    • They are concerned about any outages or oddball things they may encounter
    • They are ok with opening all 2021 at once
  • Question from Howard - Did we have any new data elements or any new XML structure or anything new that begins January 2021?
    • Because if we got anything significantly new for the first closure, may want to push that further out because of unknowns
    • Ahmar does not think there were any significant changes
    • Not aware of any new changes to reporting or immunizations for 2021.  Don't believe there were any XML changes
    • Per Lisa, there will be changes as we move forward; additions coming at the end of PI15 for the network contract
    • There will be no changes retro to January 2021
    • Per Kathleen, if part of pneumococcal vaccinations out of clinical model and somewhere else wouldn't that involve an XML change?
      • An XML change may require a 6 month lead time to accommodate
      • EDIs need the specific changes so they can react to it
      • They need the detailed specifications
      • EDIs are willing to work in tandem with the ADOs
      • EDI process includes development, put in their EHR code, roll it out to all their sites, test it inside the EHR then test in EQRS
      • The 6 month timeframe has been on the table for years with CMS
      • The program thinks the 6 months is along time when CMS is trying to make quality improvement changes to help the patients; its not an agile process
      • Lisa will ask the ADO when they will be able to provide specifications 
      • Howard request to start off with just a listing of the generic ideas and changes they are thinking about; then the EDIs can start working the ADOs and get engineering specifications on each item on the list
      • After they have the list, maybe every Friday they can take one of the items at a time and do a deeper dive on them to determine if an XML change is involved
      • Kathleen - They would like to know as soon as possible what data points will be impacted.  It is an important piece of this whole process
      • Sarah (DaVita) - agrees with Howard's approach on how they can work with the ADO in order to determine a timeline; 6 month is a good general timeline but until they know the specifics on changes its hard to give an answer; the sooner the better
      • NRAA (Howard) feels the program has not adhered to a systems development lifecycle process
      • The program needs to start telling the EDIs the details of what the system changes are so that they can be accommodated
      • Lisa - we all have to be ready to be rapidly moving forward and maybe the answer is not sending out paper but collecting it from their facilities in EQRS so they can do manual input until the EDIs are ready to batch
      • Suggesting that the EDIs are more involved in the PI planning efforts so they are aware of the priorities ahead of time; be involved and actively contribute to those conversations; there is transparency, aware of the goals and changes
      • Lisa - suggesting that the program make the EDIs aware of the features that they are considering for PI planning
      • Lisa will talk to Ahmar and Curt about the possibility of this happening
  • FKC
    • Agree to opening all of 2021 at once and not against a rolling closure
    • Would CMS consider keeping them open until the natural December closure so December 2021 would naturally close at the end of February
    • Leave all of 2021 open until the end of February
  • DaVita
    • Agree with leaving all of 2021 open until the end of February
    • In alignment with NRAAs suggestion in the timing of 90 days, 60 days, 60 days.; the more time they have the better
    • Sarah asked if this was the only time they had to provide input on the timing of 2021 submissions?
      • Per Ahmar - Need to decide soon and come up with a decision and communicate it out; also, once it it opened and issues are encountered, they can always talk about it (for example, an extension or what can be done to help the EDIs); there will be room for adjustment if needed
    • DaVita does not have any issues with opening up all clinical months at the same time
  • DCI - Vlad is OOO and not able to provide feedback for DCI
Data Reports to the LDOsNCC
  • EDI (NRAA) noticed there are a lot of NCC reports and have a lot of duplicative data within them
  • What are the reports used for?
  • What is the purpose of the reports?
  • How to best route the reports and use them with our various facilities?
  • The NCC gives the EDIs everything that is given to the networks to help them do their work with the facilities
  • NRAA agrees the report all needed but would like some dialog on what the reports are used for?  Purpose?
  • They are looking for a list of the reports, what they are used for, the intended audience and intended use of that report
  • For example like an extension of a data dictionary or similar to a report user's guide
  • Per Leah S - From a network perspective they use them not only for data clean up but also b/c EQRS does not have reports so they also use them internally; there is a difference in how they use the reports their facilities don't see a lot of the data
  • NRAA recommends creating a user guide for all of the reports that we expect the facilities to use and also a good aid for the EOCT to use in training people
  • Lisa will talk this over with Ahmar and work on having some meetings that EDI Submitters can attend with the NCC and EOCT in developing a type of guide
  • Per Janet Lea - if they are talking about new reports like data quality reports, transplant reports, etc; data dictionary's and specs were provided on manage file transfer
  • Need to figure how we can help the facilities understand how the reports can be useful to them
  • Question to DaVita and FKC - Can these reports be sent down to the facilities to see if there are any issues with the data between their EMR and EQRS?
    • Kathleen - need to understand which reports we are talking about
    • Coming from a network background, she already knows what these reports are, what they are meant to tell her and what they are used for
    • She can operationalize them at a corporate level and take the burden off the clinics
  • NCC will work with EDIs and see if the EOCT has the bandwidth to help
  • Howard suggest they can create a standing meeting on reporting with their super users to give feedback and help develop user guides
  • Should differentiate between a corporate user and a field user in some of their descriptions, they have both players
Round TableAll

Next meeting scheduled for  

Action Items:

  • DUA - check if we have ability to extend past end of the contract (5/31) Lisa Rees 
  • DUA - Research and see what would happen if we're unable to get it completed in 10 days and get back to the group Lisa Rees 
  • Look into reviewing the Roadmap in future meetings Lisa Rees (discussions still taking place)
  • Need good business rule documentation - capture in a centralized location to shared with the community Lisa Rees 
  • Look and see if there is a way FKC can put in an MBI and it give them back the SSN? Lisa Rees Lisa will take it back to the team and see about getting it put on the backlog
  • Research if it is possible to gather metrics around the SSN issue Lisa Rees 
  • Will they have Clinical Compliance reports available to them at least twice a week? Lisa Rees
  • Vendors will need the cleaned up error codes list Ahmar Wazir 
  • Request that the team that runs the database, when they do open up the clinical submissions for September through December of 2020 for specified time of 7/12 through 9/1 when it's going to close make sure that the 2021 months are NOT accidentally opened Ahmar Wazir 
  • Wants to confirm for attestations testing, the personnel file is setup in prod-preview the same way they are set up in prod? Scott Laughlin 
  • Is there an opportunity for them to test attestation batching next week before they try to do it live? Scott Laughlin 
  • Request that when system is ready for EDI's to start resubmitting, can Scott's team or whomever send an email indicating Phase 3 is now live in production and they may start resubmissions? Scott Laughlin 

DateMilestone (M) / Task (T)DescriptionPhaseStatus
2/28/2021MCode deployed to pre-prod for testing.1Complete
3/15/2021 - 3/24/2021TEDIs perform integration testing.1Complete


MEDIs sign-off on integration testing.1Complete

3/24/2021 - 3/25/2021

TADO prepares for coding deployment.1Complete


MProduction deployment.1Complete
3/31/2021MProd-Preview environment contains refreshed prod data 2Complete
2/24/2021 - 3/10/2021 TReview of phase 2 codes and finalize list of codes.  Complete
3/11/2021 - 4/30/2021TADO perform coding updates and regression testing - Phase 2 (Patient Codes) 2Complete


MProd-Preview environment data refresh.2Complete


MRemaining Phase 2 (Patient Codes) deployed to pre-prod for testing.2Complete

5/4/2021 - 6/1/2021


EDIs performs integration testing - Phase 2 (Patient Codes) 
Starting 5/4 - EDIs submit prod file in prod environment and PP2-3.  This should be the SAME file for both environments.  Review discrepancies between the feedback files and validate codes.



MEDIs sign off-on integration testing - Phase 2 (Patient Codes) 2Complete

6/2/2021 - 6/4/2021

TADO prepares for coding deployment - Phase 2 (Patient Codes) 2Complete


MProduction deployment - Phase 2 (Patient Codes) 2Complete
6/4/2021MPhase 2 (Patient Codes) live in production.2Complete
3/10/2021 - 3/17/2021TReview of phase 3 codes and finalize list of codes.  3Complete
5/12/2021 - 06/08/2021TADO perform coding updates and regression testing - Phase 3 Clinical Codes/27283Complete


MProd-Preview environment data refresh.
6/4/2021 - 6/6/2021T

EDIs SHOULD NOT submit any PATIENT files during this time period in production (to ensure same patients are in PP2-3).


EDIs to drop file into PP2-3 to establish a baseline.



MCode deployed to pre-prod for testing - Phase 3 (Clinical Codes/2728).
Reopening September 2020 to March 2021 Clinical months for submission.

6/9/2021 - 7/6/2021

TEDIs performs integration testing.

Starting 6/9 - Re-drop same file from 6/7/2021 into PP2-3.  Review feedback files from PP2-3 and validate codes.



MEDIs sign-off on integration testing - Phase 3 (Clinical Codes/2728).3


7/7/2021 - 7/11/2021

TADO prepares for coding deployment - Phase 3 (Clinical Codes/2728).3Complete
7/12/2021MPhase 3 (Clinical Codes/2728) live in production.3Complete


MEDSM Implementation Complete (Phase 1 - 3).n/aComplete

7/12/2021 - 9/15/2021


Resubmission of Clinical Data Files (September to December). 

Open July 12, 2021 at 5 a.m. Pacific (8 a.m. Eastern) and close September 15, 2021 at 11:59 p.m. Pacific Daylight Time

9/15/2021 is the official closure date for the clinical months of September, October, November, and December 2020.

CMS highly recommends completing large data submissions prior to the official clinical closure date.





Data fully submitted and ready for measure and scoring calculations.

09/20/2021 - 02/28/2022T

Submit January-September 2021 EQRS Clinical Data, ICH CAHPS Attestations, and Clinical Depression Screening and Follow-Up Plan reporting in EQRS. Additionally, all subsequent months in 2021 will open for data submission on the first day of each month (i.e., October opens October 1; November opens November 1; and December opens December 1). 

02/28/2022MThe clinical closure date for all months in 2021 is February 28, 2022 at 11:59 PM PT.n/a

Data Submission (Errors & Warnings) Milestone Dates - By Phase

Phase No.

File Type

Code Bucket Name


ADO Completion Date

LDO Testing Start Date

Testing Completion Date

Production Date



Admit Reasons

11221, 11222, 11223, 11224, 11225







Patient Codes







Clinical Codes







2728 Codes





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