Federal EHR Incentive Grant Recipient Outreach Program

The Federal EHR Incentive Grant Recipient Outreach Program is an administrative outreach initiative administered by Technology Compliance Partners (TCP). The program supports eligible grant recipients in maintaining documentation accuracy, provider awareness, and compliance readiness related to federal EHR incentive participation.

Program Charter

Administered by: Technology Compliance Partners (TCP), an independent nonprofit Health IT compliance board and vendor network governed by a board of directors.

Effective Date: December 1, 2024

Last Updated: February 11, 2026

Current Jurisdiction of Administration: State of California

I. Statement of Authority and Regulatory Framework

The Federal EHR Incentive Grant Recipient Outreach Program operates within the regulatory framework established by:

The Centers for Medicare & Medicaid Services (CMS);
The Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs, including Meaningful Use and Promoting Interoperability;
The Office of the National Coordinator for Health Information Technology (ONC) Health IT Certification Program;
Applicable federal documentation retention and audit standards.

CMS establishes participation requirements, certification standards, attestation obligations, documentation expectations, and audit procedures under the EHR Incentive framework.

As an independent nonprofit Health IT compliance board and vendor network, TCP administers this Outreach Program to fulfill documentation retention, certification verification, and reporting alignment obligations associated with federal EHR Incentive participation.

The program operates in alignment with CMS standards governing grant participation, certification verification, and audit readiness.

II. Purpose and Objectives

The Federal EHR Incentive Grant Recipient Outreach Program exists to:

Maintain accurate and audit-ready documentation relating to EHR Incentive grant recipients;
Ensure certification status records are current and properly reflected;
Reconcile outdated, incomplete, or legacy grant file records;
Promote transparency between grant recipients and regulatory bodies;
Provide proactive notification to providers regarding their certification status and program requirements;
Offer access to resources that support restoration of active certification status when necessary.

The program addresses issues including:

Outdated grant files;
Certification lapses;
Documentation drift;
Enrollment status discrepancies;
Incomplete or legacy participation records.

The program fulfills TCP's documentation and reporting obligations while supporting providers in maintaining accurate federal participation records.

III. Jurisdictional Scope

The Outreach Program applies to healthcare providers who:

Previously attested under the Medicare or Medicaid EHR Incentive Program;
Accepted federal EHR Incentive funding;
Maintain active enrollment in a Medicare or Medicaid program, including Denti-Cal or Medi-Cal within California;
Appear within TCP's vendor network reporting and documentation queue.

The program is currently administered within the State of California.

The program applies to federal EHR Incentive participation and does not modify historical attestation determinations.

IV. Scope of Activities

The Outreach Program may include:

Administrative review of legacy grant files;
Verification of certification status under ONC standards;
Verification of Medicare or Medicaid enrollment status;
Confirmation of NPI data (Type 1 and Type 2);
Review of attestation stage and funding history;
Provider outreach via primary contact methods;
Communication of certification status (Active or No Active Certification);
Documentation of communication logs;
Issuance of administrative letters, including:
- Grant transcript confirmations;
- Letters of noncompliance explainer;
- Letters of noncompliance (as applicable);
- Letters of compliance upon request and verification.

Where certification deficiencies are identified, providers may be informed of available resources, including Bridge Certification or CalDXF-related resources. Participation in those programs is voluntary and separately administered.

The Outreach Program does not require enrollment in any specific resource pathway.

V. Operational Framework

The Outreach Program follows a structured administrative cycle:

Identification of legacy or active grant files within the reporting queue;
Verification of provider enrollment and participation status;
Administrative review of certification status;
Provider outreach and confirmation of file details;
Update of file records based on verified information;
Designation of certification status (Active or No Active Certification);
Issuance of applicable documentation;
Closure of review cycle for that period.

Outreach may also occur in response to:

Federal Health IT regulatory updates;
Board-level audit cycles;
Certification standard changes;
Documentation reconciliation requirements.

VI. Documentation and Records

The Outreach Program maintains audit-ready internal records including:

Certification status logs;
Enrollment verification records;
Participation history;
Communication logs;
Administrative designations;
Issued documentation records.

Documentation that may be issued includes:

Grant record transcript confirmations;
Letters of noncompliance explainer;
Letters of noncompliance (as applicable based on certification status and regulatory context);
Letters of compliance (upon request and subject to administrative review).

VII. Limitations of Authority

CMS and applicable regulatory agencies establish participation standards, enforcement mechanisms, audit procedures, and compliance determinations under the EHR Incentive Programs.

The Outreach Program documents certification and participation status within TCP's administrative framework consistent with those standards.

Certification status designations reflect verification of ONC-certified EHR technology under applicable federal requirements.

VIII. Relationship to Other Programs

The Outreach Program operates as the foundational administrative program within TCP's Health IT compliance framework.

It may interface with:

The Bridge Certification Program (for certification stabilization resources);
The CalDXF Program (for state interoperability resources).

Each program maintains separate administrative scope and governance structure.

Participation in one program does not mandate participation in another.

IX. Duration and Sunset

The Outreach Program is tied to the lifecycle of the Federal EHR Incentive and Promoting Interoperability Programs.

The maximum projected duration of the program is seven (7) years from the close of the Meaningful Use program in 2022, unless earlier modified or sunset by TCP's governing board.

TCP may modify or sunset the program with advance public notice.

Archived versions of this Charter will remain available for transparency.

Governance and Oversight

This program operates under the oversight of TCP's governing board. Program structure, scope, and administrative procedures are subject to periodic internal review. Material changes to program scope or eligibility are approved through board governance processes and reflected in the version history below.

Definitions

Grant File: "Grant File" refers to the limited administrative transcript associated with a provider's participation in the Medicare or Medicaid EHR Incentive Program at the time of attestation and as subsequently updated through Administrative Review.; The Grant File may include, but is not limited to:; Each Grant File contains an administrative status designation, which may include:; The Grant File reflects a limited transcript of participation data and administrative status and does not necessarily include full attestation documentation unless separately retained and requested.
Reporting Queue: "Reporting Queue" refers to TCP's internal administrative review pipeline consisting of Grant Files pending verification, update, reconciliation, or documentation confirmation consistent with applicable federal documentation retention standards.; Files remain in the Reporting Queue until Administrative Review results in one of the following recorded designations:
Outreach: "Outreach" refers to formal administrative contact initiated by TCP for the purpose of verifying, updating, or reconciling Grant File information.; Outreach may occur via the primary contact method listed in the Grant File, including telephone or email, and is documented within TCP's administrative records.; Outreach is conducted for the purpose of updating participation data and certification status within the Reporting Queue.
Administrative Review: "Administrative Review" refers to the structured verification and update process conducted through Outreach for the purpose of reconciling and updating a Grant File.; Administrative Review includes:; Administrative Review concludes with a recorded designation and closure of the review cycle for that period.
Active Certification Status: "Active Certification Status" has the same meaning as defined in the Bridge Certification Program Charter and refers to verification that the provider maintains Active ONC Certification associated with their NPI under applicable federal standards.
No Active Certification Status: "No Active Certification Status" has the same meaning as defined in the Bridge Certification Program Charter and reflects verification that no Active ONC Certification is associated with the provider's NPI at the time of review.
Dispute: "Dispute" refers to a designation applied when certification, attestation, enrollment, or grant participation data cannot be conclusively reconciled due to conflicting records, irregular submissions, or material discrepancies requiring further clarification.; A Dispute designation is distinct from No Active Certification Status and reflects an unresolved administrative condition.
CEHRT Issued: "CEHRT Issued" refers to a designation applied when a provider establishes Certified Electronic Health Record Technology (CEHRT) through remediation and Active ONC Certification is verified and associated with the provider's NPI.; This designation reflects restoration of certification status within TCP's administrative framework.
Letter of Noncompliance Explainer: "Letter of Noncompliance Explainer" refers to a preliminary administrative document issued when a provider is designated with No Active Certification Status.; The Letter explains:; The Letter of Noncompliance Explainer serves as a status clarification document and does not constitute a regulatory enforcement determination.
Letter of Noncompliance: "Letter of Noncompliance" refers to an administrative document issued in limited circumstances where certification deficiencies appear to materially conflict with applicable CMS participation requirements.; Issuance is based on case-specific review and reflects certification status relative to federal program standards in effect at the time of review.
Grant Transcript: "Grant Transcript" refers to a provider-facing export of the Grant File reflecting participation data, funding history, certification designation, and administrative status as recorded within TCP's administrative framework.; Providers may request a Grant Transcript.
Documentation Retention Obligations: "Documentation Retention Obligations" refers to the recordkeeping requirements associated with participation in the Medicare and Medicaid EHR Incentive Programs, including obligations applicable to providers, grant submitters, consultants, certified EHR vendors, and related Health IT entities under CMS guidelines.; These obligations include maintaining auditable documentation for the period defined by applicable federal standards.
Audit-Ready Documentation: "Audit-Ready Documentation" refers to organized, verifiable, and time-stamped administrative records maintained in a format capable of being produced upon request consistent with applicable CMS documentation standards.
Active Enrollment: "Active Enrollment" has the same meaning as defined in the Bridge Certification Program Charter and refers to enrollment in Medicare or Medicaid in good standing, regardless of current billing volume.
Help Desk: "Help Desk" refers to TCP's administrative support channel through which providers may:; The Help Desk provides informational and administrative support within the scope of TCP's programs.

Version History

Version 1.0 – December 1, 2024 – Initial adoption
Version 1.1 – February 11, 2026 – Updated administrative framework

For related disclosures, statutory references, and program policies, see the TCP Disclosures Section.