2:00 - 2:45pm


Aaron Thompsonx
Adrienne Adkins
Adrienne Rayx

Ahmar Wazir

Anitha Chintalapatix
Anne McDermottx
Antwyn Jacksonx
Arnie Esparterox
Arthur (HUCD)x
Brandy Meadex
Branon Barrett
Cheri Jerger
Chris Brownx
Chris Mario
Curt Phillips
Danita Patel
Deb Wilsonx
Delia Housealx
Dianna Christensenx
Divya Dobbalax
Erin Wolfex
Hari Krishna
Heather Moorex
Howard Thomasx
Janet Hutchinsonx
Jason Clemx
Jay Vancil
Jennifer Baileyx
Julie Alvarezx
Justin Garciax
Justyna Sardin
Kathleen Prewittx
Kelly Llewellynx
Lakshmi Erigineni
Leah Skienx
Lisa Rees
Melissa Fieldhousex
Michael Kennedyx
Nathan Muzosx
Ozlem Taselx
Pandu Muddana
Porsche Dorseyx
Revathy Ramakrishnax
Sarah Fillingx
Scott Laughlinx
Seema Sreenivas
Shalon Quinn
Shamim Almamun
Steve Goodmanx
Timothy Jacksonx
Todd Johnsonx
Vladimir Ladikx
Yvette Brownx
Zac Cohen
Zachary Serlethx


Meeting RecordingArnie

This session will be recorded for the purpose of documenting the meeting minutes and action items. If there are any objections to the recording of this session, please make it known now. Absence of an objection to the meeting being recorded will count as consent to recording this meeting. Passcode: u#.$652b 

2021 Data Submission ExtensionAhmar

CMS Feedback

Recording for this discussion: 01:42 - 20:04

2021_2022 Clinical Closure Dates.pptx (Information in slides are as of 2/4/22, 2pm)

  • Proposed dates were determined taking into consideration the amount of data that has already been submitted; looking at CMS operational needs and program needs moving forward in the calendar year
  • This is the proposed plan to the programs leadership; seeking feedback from the EDIs
    • Closures from January through September clinical months will happen on the original plan date on February 28
    • This was the date the program proposed to close all of 2021 months from January through December
    • Given the covid variants, the program wanted to give the EDIs additional 2 months for the last quarter of 2021
    • What does the operational need at CMS driving the closure of the first three quarters?
      • You really can't do much until you close all the quarters
      • With the subset of data, CMS/program can start multiple things, there are a lot of things that happen in the backend (a subset of QIP data an be used to check the logical for engine and all the measures that happen in the backend)
      • The program can also perform some of their own analyses of research work that they do
      • Howard pointed out they still may have challenges January through September
    • NRAA would like to request for CMS/program to consider a modification on the February 28th date to be the end of March to give them one extra month for the first three quarters
      • Howard forecasts hearing a lot of noise about QIP this year b/c of the data challenges they have had
    • DaVita agrees with this proposed modification depending on the timing of when the official announcement will come out
      • They need time to shift and get their leadership on board internally
      • The extra month (end of March) will allow DaVita to react to the change
    • DCI agrees with the proposed end of March date
      • 95% of data should be submitted
      • May be a problem in QIP; a penalty QIP may have on clinics; may impact the scores to be lower
    • FKC is in agreement with the proposed end of March date
      • Kathleen would like to extend a thanks for CMS/program in considering an extension
  • Another proposed option
    • If we put the first 2 quarters ending on February 28 and then the second quarter ending on May 2
      • EDIs do not recommend this option
      • There are different performance levels with different people; some impacted by covid differently
  • Per Delia - she appreciates the EDIs flexibility; the program has some needs to accomplish and goal is to try their data collection back on their normal schedule to minimize further impact on the program
  • For 2022 Clinical Closure Dates
    • January, February, March - Planned Closure Date = May 31, 2022
    • Getting to normal routine which is end of March plus 60 days
    • April 2022 - Planned Closure Date = June 30, 2022
    • May 2022 - Planned Closure Date = August 1, 2022
    • June 2022 - Planned Closure Date = August 31, 2022
  • All the EDIs are on board with the above proposed dates for the 2022 Clinical Closure Dates
  • Howard suggest to add and asterisk for March and notes below "resume normal cadence" to represent being back to normal
  • What is the ETA on making the final decision and communication for the proposed option/dates above?
    • The program will propose this plan to leadership next week
    • Per Ahmar, hoping for a decision end of next week/early the following week
CCSQ Support CentralBrandy/Justin

Demo - Sending comments directly to Service Center

Recording for this discussion: 20:24 - 28:48

  • Demo presented by ServiceNow team (listen/view recording for mock screens and workflow process)
  • Presented the capability to add comments to tickets and also reopen resolved tickets via the web portal
  • What is the time period between resolved and closed status?
    • It is five business days, the user has five business days to reopen your ticket, after that it's going to be closed
    • Once the ticket has been closed, the user cannot "revive" or make any updates to the ticket
    • ServiceNow team does have on their backlog for closed tickets, a button will be added to create a new ticket from the ticket itself
  • NRAA has their own ticketing system, will the ticket from the NRAA system get "linked/merged" into the new CCSQ Support Central portal and create a new ticket?
    • NRAA tickets for their customer automatically get routed to the QualityNet support for EQRS; when that ticket is routed to that email address somebody from on the CMS side takes that information today and puts it into the CMS ServiceNow system
    • NRAA would like to know if they will have access to the CCSQ Support Central system in order to see the newly created ticket?  Currently, when that new ticket is created on the CMS side, it is created for the customer that submitted it, not the renal healthcare organization
    • Per Brandy, the email that is being sent to CMS does not have anyone manually entering the ticket, it is automatically created using the details and body of the email. Whomever is the customer on that ticket will be the customer on the CCSQ Support Central portal ticket
    • NRAA will not be able to receive the ticket unless someone on NRAA is the one that initiated the email for the ticket to be created
    • ServiceNow team did get the use case for NRAA to be able to view it and take it but at this time it is not part of the ServiceNow data model so this use case cannot be done
    • There is an item on the backlog to be able to copy others on an email so the person copied will be able to see the ticket as it goes through the workflow process
  • Per Howard the CCSQ Support Central ticketing system works for NRAA and their current NRAA ticketing system is accommodated by the CCSQ Support Central system
CMS RolesScott

CMS Role(s) Requests

Recording for this discussion: 29:08 - 31:41

  • Currently seeing some CMS role requests happening in EQRS from various EDI support communities
  • A request from CMS to the community to maybe to inquire with training documentation or with EDIs staff more directly on why these roles are being requested
  • DaVita and FKC would like Scott to send examples of CMS role requests so they can reach out to their communities and determine the root cause of the request (Action Item)
EDI Submitter's Progress (upcoming feature development)EDIs


  • What is the timing of the 2744 reports? When will they be expect to be in production
    • Per Michael it is still slated for soon; he wanted to release this week but there were some other 2744 issues that blocked moving them to production
    • Michael is fixing the bug on the counts for discontinue
    • The dialysis ones are ready to go and still finalizing up the transplant 2744 one
    • The reports may be in production possibly next week
    • Per Howard, NRAA is getting the 2728 report via the NCC; finding that maybe 20% of their patients are not having patient org ID, but when they go in through SUI they see those patients there and also have a patient org ID and have clinical data coming in, but on the 2728 report the patient org ID is going null
    • Per Michael this is completely different than the 2744; the 2728 problem encountered should not persist on the 2744s
  • At the NCC meeting this week, it came up about the near match reporting
    • Asked Michael if he can get that going; the report has been very useful to DaVita
    • It is on Michael's backlog but won't be done next week
    • The 2744 work has to be done first
    • Michael has a data quality feature as an enabler in this PI and will add this report as a bullet under this feature


  • What are the thoughts on the missing patient org ID on the 2728?
    • Per Kelly, a ticket has been created for some assistance
    • It was responded to Kelly and Heather by the CMS help desk that they did not understand what to do so they provided further clarification it was the NCC reports then the ticket was forwarded to Dianna and Janet
    • Dianna responded and said they can't do anything with this because if there was not a patient ID sent in, NCC can't pull it on the report
    • Per Janet their response was that they were not able to match that record to the patient org ID to the EDI submitter
    • If they cannot match it to the patient org ID with the EDI submitter, it will come up blank
    • NRAA will get the ticket over to Michael for him to research


    • Kathleen wanted to follow up and get an update on the ICH CAHPS Attestation reporting
    • She sent Shalon, Scott and others an example report that they used to get from Ventech
    • Per Todd he did follow up with Dianna and she sent him a response but he still needs to circle back with Dianna (Action Item)


    • No updates at this time

Action Items:

  • DaVita and FKC would like Scott to send examples of CMS role requests so they can reach out to their communities and determine the root cause of the request Scott Laughlin  
  • Kathleen request an update on the ICH CAHPS Attestation report.  Todd will follow up with Dianna and get back to the group (Todd Johnson)
  • Request from Chris - display/capture EQRS rule updates or "hot-fix"/non major release dates that can be shared with the EDI Submitters that may impact their ability to correct/update patient data
    • Scott will research a way to be able to identify a feature that a rule update or "hot-fix" impacts, so the EDI Submitters are aware of the change Scott Laughlin
  • Scott will discuss revisiting the DaVita effective date and date of death issue with Lisa Scott Laughlin
    • Scott will provide a response to Nathan (1/14/22) 

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