Health Information Network (HIN) Quarterly AttestationState Fiscal Year 2025

Health Information Network (HIN) Quarterly Attestation

State Fiscal Year 2025

This form provides attestation if the hospital participates and is connected to one of the two statewide HINs: Mississippi Hospital Association (MHA) and the Mississippi State Medical Association (MSMA).

In SFY 2025, in order to receive the HIN portion of the QIPP payment, hospitals will be required to certify their actual connection to, and participation in, a statewide HIN. The statewide HIN to which the hospital is connected must have the capability to receive admit, discharge and transfer (ADT) information from the hospital and transmit that information to Medicaid and/or its designee.

The hospitals’ HIN connection is expected to support clinical and ADT data sharing for Medicaid beneficiaries receiving care at their hospitals. During SFY 2025, but not later than the end of the first quarter ended September 30, 2024, hospitals will be required to submit ADT information to the HIN and attest to that submission in order to receive the HIN component of QIPP.

Submitter Name*

Submitter Title*

Submitter Email*

Facility Name*

Select

Hospital Administrator Name*

Hospital Administrator Phone Number*

Phone

Hospital Administrator Email*

State Fiscal Year*

SFY 2025

Quarter of SFY*

Select or enter value

Do you participate in a Statewide Health Information Network (HIN)?*

Yes

The hospital is participating in a statewide Health Information Network ("HIN"). By marking "Yes", the hospital is attestating that the hospital participates and is connected to one of the two statewide HINS: Mississippi Hospital Association (MHA) and the Mississippi State Medical Association (MSMA). The hospital is confirming its connection to and participation in the statewide HIN with a current valid contract. The hospital's HIN connection is expected to support clinical and admission, discharge and transfer (ADT) data sharing for Medicaid beneficiaries.

Do you have a HIN contract effective as the date of this attestation?*

Yes

Are you currently submitting ADT data to the HIN?*

Yes

I hereby certify that the information above is true and accurate to the best of our ability and current internal systems can support the HIN. I understand that this information will be used to determine the Medicaid program's compliance with the SFY 2025 preprint submitted by the Mississippi Division of Medicaid which included funding tied to the creation and usage of a HIN for the rating period from July 1, 2024 through June 30, 2025.

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